| NPI | 1891813408 |
|---|---|
| Former Legal Business Name | PLATINUM DENTAL GROUP SURGICAL CENTER, LLC |
| Entity Type | Organization |
| Authorized Contact | MARK D THEBAUT Owner 770-751-3115 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA 9113) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: GA 9113) |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2020-08-22 |