| Gwinnett Childrens Dentistry | |
|
609 Beaver Ruin Rd Suite A Lilburn GA 30047 | |
| (770) 925-3300 | |
| (770) 925-3302 |
| Full Name | Gwinnett Childrens Dentistry |
|---|---|
| Speciality | Dentist - Pediatric Dentistry |
| Location | 609 Beaver Ruin Rd, Lilburn, Georgia |
| Authorized Official Name and Position | Mark Denny Thebaut (OWNER/DENTIST) |
| Authorized Official Contact | 6789906301 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Gwinnett Childrens Dentistry 609 Beaver Ruin Rd Suite A Lilburn GA 30047 Ph: (770) 925-3300 | Gwinnett Childrens Dentistry 609 Beaver Ruin Rd Suite A Lilburn GA 30047 Ph: (770) 925-3300 |
| NPI Number | 1255665667 |
|---|---|
| Provider Enumeration Date | 10/01/2009 |
| Last Update Date | 10/01/2009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255665667 | NPI | - | NPPES |
| 151700972A | Medicaid | GA | |
| 232076497A | Medicaid | GA | |
| 177273740D | Medicaid | GA | |
| 149199935A | Medicaid | GA | |
| 000185875E | Medicaid | GA | |
| 591447276B | Medicaid | GA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | (* (Not Available)) | Secondary |
| 1223P0221X | Dentist - Pediatric Dentistry | (* (Not Available)) | Primary |
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