{
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"EIN": null,
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"IsOrgSubpart": "N",
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"LastName": null,
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"FirstLineMailingAddress": "930 EBONY AVE APT A",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "IMPERIAL BEACH",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91932-2877",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "CARILLO PUERTO",
"SecondLinePracticeLocationAddress": "1536-2023",
"PracticeLocationAddressCityName": "TIJUANA",
"PracticeLocationAddressStateName": "BAJA CALIFORNIA",
"PracticeLocationAddressPostalCode": "22000",
"PracticeLocationAddressCountryCode": "MX",
"PracticeLocationAddressTelephoneNumber": "619-272-9021",
"PracticeLocationAddressFaxNumber": "619-329-9663",
"EnumerationDate": "03/27/2024",
"LastUpdateDate": "03/27/2024",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CUEVAS ALVAREZ",
"AuthorizedOfficialFirstName": "FABIOLA",
"AuthorizedOfficialMiddleName": "YAREL",
"AuthorizedOfficialTitle": "DENTIST",
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"AuthorizedOfficialCredential": "DDS",
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"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."
}
}
}
}