{
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"IsOrgSubpart": "N",
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"OrgName": "FELDKAMP CAL SELECT DENTAL GROUP, INC.",
"LastName": null,
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"MiddleName": null,
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"FirstLineMailingAddress": "PO BOX 10669",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SAN BERNARDINO",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92423-0669",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "909-723-1088",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "164 W HOSPITALITY LN # 107",
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"PracticeLocationAddressCityName": "SAN BERNARDINO",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "92408-3316",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "909-453-6600",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "08/01/2018",
"LastUpdateDate": "08/01/2018",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FELDKAMP",
"AuthorizedOfficialFirstName": "IRVING",
"AuthorizedOfficialMiddleName": "MOORE",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": "III",
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "909-723-1088",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "21985",
"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."
}
}
}
}