NPIMap

Organization Active NPI

Mark D Thebaut DDS PC

Doing business as Gwinnett Childrens Dentistry

  • Pediatric Dentistry
  • Lilburn, GA
National Provider Identifier
1447377130
Registry record updated Jun 18, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
9113 Issued in GA
Legal business name
MARK D THEBAUT DDS PC
Doing business as
Gwinnett Childrens Dentistry
Practice address
609 Beaver Ruin Rd NW
Suite a
Lilburn, GA 30047-3401
Phone
(770) 925-3301
Fax
(770) 709-0001
NPI assigned
Mar 26, 2007
Last updated
Jun 18, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 18, 2008

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

Authorized official

Name
Dr. Mark D Thebaut, DDSNPI 1245332238
Title
Owner
Phone
(770) 925-3301

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Dentistry 1223P0221X 9113 GA Primary

Addresses

Primary practice location

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

Mailing address

609 Beaver Ruin Rd NW
Suite a
Lilburn, GA 30047-3401
Phone (770) 925-3300

Other names 1

  • Gwinnett Childrens Dentistry Doing business as

National Provider Directory

National Provider Directory
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.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

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": "1213747200000",
    "number": "1447377130",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "609 BEAVER RUIN RD NW",
            "address_2": "SUITE A",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300473401",
            "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 NW",
            "address_2": "SUITE A",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300473401",
            "telephone_number": "770-925-3301",
            "fax_number": "770-709-0001"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARK D THEBAUT DDS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-26",
        "last_updated": "2008-06-18",
        "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": "770-925-3301",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "GA",
            "license": "9113",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Gwinnett Childrens Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 Jun 18, 2008; 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.