| Platinum Dental Group Gainesville, Llc | |
|
3535 Thompson Bridge Rd Gainesville GA 30506 | |
| (770) 534-5374 | |
| (770) 534-5591 |
| Full Name | Platinum Dental Group Gainesville, Llc |
|---|---|
| Speciality | Dentist - Pediatric Dentistry |
| Location | 3535 Thompson Bridge Rd, Gainesville, 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 |
|---|---|
| Platinum Dental Group Gainesville, Llc 3535 Thompson Bridge Rd Gainesville GA 30506 Ph: (770) 534-5374 | Platinum Dental Group Gainesville, Llc 3535 Thompson Bridge Rd Gainesville GA 30506 Ph: (770) 534-5374 |
| NPI Number | 1083948491 |
|---|---|
| Provider Enumeration Date | 10/01/2009 |
| Last Update Date | 10/01/2009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1083948491 | NPI | - | NPPES |
| 000185875H | Medicaid | GA | |
| 232076497C | Medicaid | GA | |
| 149199935C | Medicaid | GA | |
| 177273740C | Medicaid | GA | |
| 151700972D | Medicaid | GA | |
| 591447276D | 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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