{
"Npi": {
"NPI": "1134660913",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "TRITON DENTAL, LLC",
"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": "PO BOX 219",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MARIPOSA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "95338-0219",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "559-683-4662",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "49722 ROAD 426",
"SecondLinePracticeLocationAddress": "SUITE 104",
"PracticeLocationAddressCityName": "OAKHURST",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "93644-9047",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "559-683-4662",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/14/2017",
"LastUpdateDate": "03/14/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WIEG",
"AuthorizedOfficialFirstName": "TIMOTHY",
"AuthorizedOfficialMiddleName": "MICHAEL",
"AuthorizedOfficialTitle": "CLINICAL DIRECTOR",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.D.S.",
"AuthorizedOfficialTelephoneNumber": "909-269-1277",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "60387",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}