Provider Demographics
NPI:1750491239
Name:THIBAULT, MARK S (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:THIBAULT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 TARA HILLS DR
Mailing Address - Street 2:SUITE K
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2531
Mailing Address - Country:US
Mailing Address - Phone:510-724-2074
Mailing Address - Fax:510-724-3430
Practice Address - Street 1:1330 TARA HILLS DR
Practice Address - Street 2:SUITE K
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2531
Practice Address - Country:US
Practice Address - Phone:510-724-2074
Practice Address - Fax:510-724-3430
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA364401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice