{
"Npi": {
"NPI": "1376616219",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "THIELKE",
"FirstName": "FREDERICK",
"MiddleName": "LOWELL",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "DMD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "3643 WALTON WAY EXT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "AUGUSTA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30909-4507",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "706-738-7129",
"MailingAddressFaxNumber": "706-738-6684",
"FirstLinePracticeLocationAddress": "3643 WALTON WAY EXT",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "AUGUSTA",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30909-4507",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "706-738-7129",
"PracticeLocationAddressFaxNumber": "706-738-6684",
"EnumerationDate": "11/16/2006",
"LastUpdateDate": "06/08/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "10249",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}