{
"Npi": {
"NPI": "1043678055",
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"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "COTTONWOOD DENTAL ASSOCIATES PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "830 S MAIN ST",
"SecondLineMailingAddress": "SUITE 1 D",
"MailingAddressCityName": "COTTONWOOD",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "86326-4620",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "928-634-5566",
"MailingAddressFaxNumber": "928-634-1363",
"FirstLinePracticeLocationAddress": "830 S MAIN ST",
"SecondLinePracticeLocationAddress": "SUITE 1 D",
"PracticeLocationAddressCityName": "COTTONWOOD",
"PracticeLocationAddressStateName": "AZ",
"PracticeLocationAddressPostalCode": "86326-4620",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "928-634-5566",
"PracticeLocationAddressFaxNumber": "928-634-1363",
"EnumerationDate": "02/04/2016",
"LastUpdateDate": "02/04/2016",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WESTOVER",
"AuthorizedOfficialFirstName": "BRUCE",
"AuthorizedOfficialMiddleName": "EDWIN",
"AuthorizedOfficialTitle": "OWNER/DENTIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "928-634-5566",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "D03477",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}