NPIMap

Organization Active NPI

Platinum Dental Group Lilburn, LLC

  • Pediatric Dentistry
  • Lilburn, GA
National Provider Identifier
1609100015
Registry record updated Oct 1, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
Legal business name
PLATINUM DENTAL GROUP LILBURN, LLC
Practice address
609 Beaver Ruin Rd
Suite a
Lilburn, GA 30047
Phone
(770) 709-0000
Fax
(770) 925-3302
NPI assigned
Oct 1, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 1, 2009

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

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X
Pediatric DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223P0221X Primary

Addresses

Primary practice location

609 Beaver Ruin Rd
Suite a
Lilburn, GA 30047

Mailing address

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

Other identifiers 6

IdentifierTypeStateIssuer
000185875JMedicaidGA
232076497BMedicaidGA
151700972BMedicaidGA
591447276CMedicaidGA
832239687AMedicaidGA
149199935BMedicaidGA

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.

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

NPI Registry JSON

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": "1609100015",
    "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": "770-709-0000",
            "fax_number": "770-925-3302"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "609 BEAVER RUIN RD",
            "address_2": "SUITE A",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "30047",
            "telephone_number": "770-709-0000",
            "fax_number": "770-925-3302"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PLATINUM DENTAL GROUP LILBURN, LLC",
        "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": "000185875J",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "232076497B",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "151700972B",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "591447276C",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "832239687A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "149199935B",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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 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.