NPIMap

Organization Active NPI

Platinum Dental of Lilburn

  • General Practice Dentistry
  • Lilburn, GA
National Provider Identifier
1154448850
Registry record updated Mar 25, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
9113 Issued in GA
Legal business name
PLATINUM DENTAL OF LILBURN
Practice address
609 Beaver Ruin Rd NW Ste a
Lilburn, GA 30047-3401
Phone
(770) 709-0000
Fax
(770) 925-3302
NPI assigned
Mar 26, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 25, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Mark D Thebaut, DDS
Title
Owner
Phone
(770) 709-0000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X 9113 GA Primary

Addresses

Primary practice location

609 Beaver Ruin Rd NW Ste a
Lilburn, GA 30047-3401

Mailing address

609 Beaver Ruin Rd NW Ste a
Lilburn, GA 30047-3401
Phone (770) 709-0000

Other names 1

  • Platinum Dental Lilburn, LLC Former legal business name

National Provider Directory

National Provider Directory
Tax ID family
Platinum Dental Group Lilburn LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174867200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1237939200000",
    "number": "1154448850",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "609 BEAVER RUIN RD NW STE A",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300473401",
            "telephone_number": "770-709-0000",
            "fax_number": "770-925-3302"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "609 BEAVER RUIN RD NW STE A",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300473401",
            "telephone_number": "770-709-0000",
            "fax_number": "770-925-3302"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PLATINUM DENTAL OF LILBURN",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-26",
        "last_updated": "2009-03-25",
        "status": "A",
        "authorized_official_last_name": "THEBAUT",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "770-709-0000",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "GA",
            "license": "9113",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Platinum Dental Lilburn, LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Lilburn, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.