Provider Demographics
NPI:1396106142
Name:TEBO DENTISTRY FOR KIDS MARIETTA LLC
Entity type:Organization
Organization Name:TEBO DENTISTRY FOR KIDS MARIETTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
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:770-925-3300
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:
Mailing Address - Fax:
Practice Address - Street 1:2155 POST OAK TRITT RD
Practice Address - Street 2:SUITE 450
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8620
Practice Address - Country:US
Practice Address - Phone:770-925-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty