{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "SAMUEL DEMIRDJI, DDS, MS, INC",
"LastName": null,
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"NamePrefix": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "7199 BOULDER AVE",
"SecondLineMailingAddress": "SUITE 5",
"MailingAddressCityName": "HIGHLAND",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92346-3398",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "909-864-6510",
"MailingAddressFaxNumber": "909-864-7410",
"FirstLinePracticeLocationAddress": "7199 BOULDER AVE",
"SecondLinePracticeLocationAddress": "SUITE 5",
"PracticeLocationAddressCityName": "HIGHLAND",
"PracticeLocationAddressStateName": "CA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "909-864-6510",
"PracticeLocationAddressFaxNumber": "909-864-7410",
"EnumerationDate": "01/27/2015",
"LastUpdateDate": "01/27/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DEMIRDJI",
"AuthorizedOfficialFirstName": "SAMUEL",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.D.S. , M.S.",
"AuthorizedOfficialTelephoneNumber": "909-864-6510",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223X0400X",
"TaxonomyName": "Orthodontics and Dentofacial Orthopedics Dentistry",
"LicenseNumber": "48447",
"LicenseNumberStateCode": "CA",
"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."
}
}
}
}