Provider Demographics
NPI:1447377130
Name:MARK D THEBAUT DDS PC
Entity type:Organization
Organization Name:MARK D THEBAUT DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:THEBAUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-925-3301
Mailing Address - Street 1:609 BEAVER RUIN RD NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3401
Mailing Address - Country:US
Mailing Address - Phone:770-925-3300
Mailing Address - Fax:770-925-3302
Practice Address - Street 1:609 BEAVER RUIN RD NW
Practice Address - Street 2:SUITE A
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3401
Practice Address - Country:US
Practice Address - Phone:770-925-3301
Practice Address - Fax:770-709-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA91131223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty