{
"Npi": {
"NPI": "1245355312",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "DAVID C BASTACKY DMD PA",
"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": "516 N ROLLING RD",
"SecondLineMailingAddress": "SUITE 104",
"MailingAddressCityName": "BALTIMORE",
"MailingAddressStateName": "MD",
"MailingAddressPostalCode": "21228-4140",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "410-744-4222",
"MailingAddressFaxNumber": "410-744-2472",
"FirstLinePracticeLocationAddress": "516 N ROLLING RD",
"SecondLinePracticeLocationAddress": "SUITE 104",
"PracticeLocationAddressCityName": "BALTIMORE",
"PracticeLocationAddressStateName": "MD",
"PracticeLocationAddressPostalCode": "21228-4140",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "410-744-4222",
"PracticeLocationAddressFaxNumber": "410-744-2472",
"EnumerationDate": "03/20/2007",
"LastUpdateDate": "04/20/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BASTACKY",
"AuthorizedOfficialFirstName": "DAVID",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "DOCTOR OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DMD PA",
"AuthorizedOfficialTelephoneNumber": "410-744-4222",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223S0112X",
"TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
"LicenseNumber": "10337",
"LicenseNumberStateCode": "MD",
"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."
}
}
}
}