{
"Npi": {
"NPI": "1326301144",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "KELLER",
"FirstName": "JESSICA",
"MiddleName": "D",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "DDS",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "DOMBROSKI",
"OtherFirstName": "JESSICA",
"OtherMiddleName": "A",
"OtherNamePrefix": "DR.",
"OtherNameSuffix": null,
"OtherCredential": "DDS",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "3416 WOODLAWN STREET",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "HOPEWELL",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "23860",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "804-458-6733",
"MailingAddressFaxNumber": "804-541-0416",
"FirstLinePracticeLocationAddress": "3416 WOODLAWN STREET",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "HOPEWELL",
"PracticeLocationAddressStateName": "VA",
"PracticeLocationAddressPostalCode": "23860",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "804-458-6733",
"PracticeLocationAddressFaxNumber": "804-541-0416",
"EnumerationDate": "06/18/2012",
"LastUpdateDate": "01/07/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "DN19726",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "0401414614",
"LicenseNumberStateCode": "VA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}