{
"Npi": {
"NPI": "1063242691",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BROCK A VAN GORDON DMD, 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": "6485 SW BORLAND RD STE G",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "TUALATIN",
"MailingAddressStateName": "OR",
"MailingAddressPostalCode": "97062-9762",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "503-878-4163",
"MailingAddressFaxNumber": "833-438-7620",
"FirstLinePracticeLocationAddress": "6485 SW BORLAND RD STE G",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "TUALATIN",
"PracticeLocationAddressStateName": "OR",
"PracticeLocationAddressPostalCode": "97062-9762",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "503-878-4163",
"PracticeLocationAddressFaxNumber": "833-438-7620",
"EnumerationDate": "08/07/2024",
"LastUpdateDate": "07/11/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "VAN GORDON",
"AuthorizedOfficialFirstName": "BROCK",
"AuthorizedOfficialMiddleName": "ASHLEY",
"AuthorizedOfficialTitle": "OWNER/ DENTIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DMD",
"AuthorizedOfficialTelephoneNumber": "503-730-4924",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QS1200X",
"TaxonomyName": "Sleep Disorder Diagnostic Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}