{
"Npi": {
"NPI": "1326618968",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PENN DENTAL GROUP PLLC",
"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": "403 OSPREY CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SOUTHLAKE",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "76092-5851",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "215-796-2967",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "4920 TEASLEY LN",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DENTON",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "76210-3901",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "940-566-1066",
"PracticeLocationAddressFaxNumber": "940-566-1067",
"EnumerationDate": "06/27/2021",
"LastUpdateDate": "06/27/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LEE",
"AuthorizedOfficialFirstName": "SANGHUN",
"AuthorizedOfficialMiddleName": "S",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DMD",
"AuthorizedOfficialTelephoneNumber": "215-796-2967",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}