{
"Npi": {
"NPI": "1013794791",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "KHADRA",
"FirstName": "MOHAMMAD TAREQ",
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": "DDS",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "KHADRA",
"OtherFirstName": "TAREQ",
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": "DDS",
"OtherLastNameTypeCode": "5",
"FirstLineMailingAddress": "18530 AMBROSIO CIR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CORONA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92881-3411",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "401-225-2455",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2675 S ABILENE ST STE 135",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "AURORA",
"PracticeLocationAddressStateName": "CO",
"PracticeLocationAddressPostalCode": "80014-2363",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "401-225-2455",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "09/14/2023",
"LastUpdateDate": "03/06/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "00205725",
"LicenseNumberStateCode": "CO",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "109296",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}