Provider Demographics
NPI:1962634543
Name:PLATINUM DENTAL GROUP LILBURN LLC
Entity Type:Organization
Organization Name:PLATINUM DENTAL GROUP LILBURN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DENNY
Authorized Official - Last Name:THEBAUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-990-6301
Mailing Address - Street 1:PO BOX 1953
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30048-1953
Mailing Address - Country:US
Mailing Address - Phone:770-709-0000
Mailing Address - Fax:770-925-3302
Practice Address - Street 1:609 BEAVER RUIN RD.
Practice Address - Street 2:STE A
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047
Practice Address - Country:US
Practice Address - Phone:770-709-0000
Practice Address - Fax:770-925-3302
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLATINUM DENTAL GROUP LILBURN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0091131223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA151700972BMedicaid