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1053911396 NPI number — KO DENTAL GROUP, PC

NPI Number: 1053911396
Health Care Provider/Practitioner: KO DENTAL GROUP, PC

Information about “1053911396” NPI (KO DENTAL GROUP, PC) exists in 1053911396 in HTML format HTML  |  1053911396 in plain Text format TXT  |  1053911396 in PDF (Portable Document Format) PDF  |  1053911396 in an XML format XML  formats.

NPI Number : 1053911396 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1053911396",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "KO DENTAL GROUP, PC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": "6",
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "302 S. AVENUE Q",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "CLIFTON",
    "MailingAddressStateName": "TX",
    "MailingAddressPostalCode": "76634",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "254-675-3518",
    "MailingAddressFaxNumber": "254-675-1262",
    "FirstLinePracticeLocationAddress": "302 S. AVENUE Q",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "CLIFTON",
    "PracticeLocationAddressStateName": "TX",
    "PracticeLocationAddressPostalCode": "76634",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "254-675-3518",
    "PracticeLocationAddressFaxNumber": "254-675-1262",
    "EnumerationDate": "10/27/2020",
    "LastUpdateDate": "07/21/2022",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "CLARK",
    "AuthorizedOfficialFirstName": "LYNDA",
    "AuthorizedOfficialMiddleName": "MARLIESSA",
    "AuthorizedOfficialTitle": "AM",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": "254-784-0508",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "122300000X",
        "TaxonomyName": "Dentist",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X 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."
      }
    }
  }
}
                
            

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