Mark D. Thebaut, D.D.S, PC Dba

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

Legal business name

MARK D. THEBAUT, D.D.S, PC DBA

Doing business as

Gwinnett Childrens Dentistry

Practice address

609 Beaver Ruin Rd
Suite a
Lilburn, GA 30047

Phone

(770) 925-3300

Fax

(770) 925-3302

NPI assigned

Oct 1, 2009

Organization subpart

No

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

Authorized official

Name

Mr. Mark Denny Thebaut, DDS

Title

Owner/Dentist

Phone

(678) 990-6301

Specialties & licenses 2

Addresses

Other identifiers 6

Other names 1

• Gwinnett Childrens Dentistry Doing business as

Tax ID family

Gwinnett Childrens Dentistry2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

• Mark D Thebaut DDS PC

  dba Gwinnett Childrens Dentistry

  • Pediatric Dentistry
  • Lilburn, GA
  • NPI 1447377130
  NPD tax ID

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

{
    "created_epoch": "1254355200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1254355200000",
    "number": "1255665667",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "609 BEAVER RUIN RD",
            "address_2": "SUITE A",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "30047",
            "telephone_number": "770-925-3300",
            "fax_number": "770-925-3302"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "609 BEAVER RUIN RD",
            "address_2": "SUITE A",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "30047",
            "telephone_number": "770-925-3300",
            "fax_number": "770-925-3302"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARK D. THEBAUT, D.D.S, PC DBA",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-10-01",
        "last_updated": "2009-10-01",
        "status": "A",
        "authorized_official_last_name": "THEBAUT",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "DENNY",
        "authorized_official_title_or_position": "OWNER/DENTIST",
        "authorized_official_telephone_number": "678-990-6301",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223P0221X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "151700972A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "232076497A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "177273740D",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "149199935A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000185875E",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "591447276B",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Gwinnett Childrens Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Ramon Ulises Mares Rios, PMHNP-BC
• Margaret H. Lee LLC
• Maria C. Santana,LLC
• David P Marion, D.D.S.
• Mark D Thebaut DDS PC (Gwinnett Childrens Dentistry)
• Seaniece Dona Martin
• Shellis Martin
• Jennie Mathen, NP-C
• Matrix Rehabilitation-Georgia Inc (Physiotherapy Associates)
• Michael E Mayfield, M.D.

• Pediatric Dentistry in Lilburn, GA
• Providers in Lilburn, GA by specialty
• Pediatric Dentistry in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 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.