Platinum Dental Group Surgical Center

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

9113 Issued in GA

Legal business name

PLATINUM DENTAL GROUP SURGICAL CENTER

Practice address

1345 Hembree Rd
Roswell, GA 30076-3816

Phone

(770) 751-3115

Fax

(678) 990-1065

NPI assigned

Mar 26, 2007

Organization subpart

No

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) 751-3115

Specialties & licenses 2

Addresses

Other names 1

• Platinum Dental Group Surgical Center, LLC Former legal business name

Locations

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

{
    "created_epoch": "1174867200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757548800000",
    "number": "1891813408",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1345 HEMBREE RD",
            "city": "ROSWELL",
            "state": "GA",
            "postal_code": "300763816",
            "telephone_number": "770-751-3115",
            "fax_number": "678-990-1065"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1345 HEMBREE RD",
            "city": "ROSWELL",
            "state": "GA",
            "postal_code": "300763816",
            "telephone_number": "770-751-3115",
            "fax_number": "678-990-1065"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PLATINUM DENTAL GROUP SURGICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-26",
        "last_updated": "2025-09-11",
        "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": "770-751-3115",
        "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": false
        },
        {
            "code": "1223P0221X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "GA",
            "license": "9113",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Platinum Dental Group Surgical Center, LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• David Eugene Pittman Jr., PT, ATC
• Michael R Pitts, PSY.D.
• PKW Wellness LLC
• Christina C Plaice, MA, LPC
• Leah Shissias Planchard, MS, OTR/L
• Platinum Dental of Roswell
• Samantha Jane Platta, LCSW
• Erin Pohlschmidt
• Sai Rohit Polakam, RBT
• Brady Polana, LMSW

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

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2025; 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.