{
"Npi": {
"NPI": "1275835407",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "UNITED DENTAL GROUP",
"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": "434 CAJON ST",
"SecondLineMailingAddress": "SUITE 101",
"MailingAddressCityName": "REDLANDS",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92373-5978",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "909-793-8793",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "434 CAJON ST",
"SecondLinePracticeLocationAddress": "SUITE 101",
"PracticeLocationAddressCityName": "REDLANDS",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "92373-5978",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "909-793-8793",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/19/2010",
"LastUpdateDate": "11/19/2010",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DELARA",
"AuthorizedOfficialFirstName": "RAFAELA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "ADMINISTRATOR",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "909-793-8793",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "57581",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "57930",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "46985",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "59318",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "58057",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "53832",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223P0300X",
"TaxonomyName": "Periodontics",
"LicenseNumber": "38226",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223S0112X",
"TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
"LicenseNumber": "24358",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "124Q00000X",
"TaxonomyName": "Dental Hygienist",
"LicenseNumber": "25296",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223X0400X",
"TaxonomyName": "Orthodontics and Dentofacial Orthopedics Dentistry",
"LicenseNumber": "48644",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
}
]
}
}
}