NPIMap

Organization Active NPI

Platinum Dental Group Lilburn LLC

  • Pediatric Dentistry
  • Lilburn, GA
National Provider Identifier
1962634543
Registry record updated Aug 17, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
DN009113 Issued in GA
Legal business name
PLATINUM DENTAL GROUP LILBURN LLC
Practice address
609 Beaver Ruin Rd.
Ste a
Lilburn, GA 30047
Phone
(770) 709-0000
Fax
(770) 925-3302
NPI assigned
Aug 17, 2009
Organization subpart
Yes
Parent organization
PLATINUM DENTAL GROUP LILBURN LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 17, 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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223P0221X DN009113 GA Primary

Addresses

Primary practice location

609 Beaver Ruin Rd.
Ste a
Lilburn, GA 30047

Mailing address

PO Box 1953
Lilburn, GA 30048-1953
Phone (770) 709-0000

Other identifiers 1

IdentifierTypeStateIssuer
151700972BMedicaidGA

National Provider Directory

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

Other organizations with this tax ID 2

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

Locations

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

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

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

{
    "created_epoch": "1250467200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1250467200000",
    "number": "1962634543",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1953",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300481953",
            "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": "STE 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": "YES",
        "parent_organization_legal_business_name": "PLATINUM DENTAL GROUP LILBURN LLC",
        "enumeration_date": "2009-08-17",
        "last_updated": "2009-08-17",
        "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": "1223P0221X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "GA",
            "license": "DN009113",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "151700972B",
            "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 Aug 17, 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.