{
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"LastName": null,
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"FirstLineMailingAddress": "90-05 70TH DRIVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FOREST HILLS",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "11375",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "718-261-0260",
"MailingAddressFaxNumber": "718-261-4742",
"FirstLinePracticeLocationAddress": "66-25 MAURICE AVE",
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"PracticeLocationAddressCityName": "WOODSIDE",
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"PracticeLocationAddressTelephoneNumber": "718-651-5941",
"PracticeLocationAddressFaxNumber": "718-261-4742",
"EnumerationDate": "05/03/2007",
"LastUpdateDate": "11/30/2012",
"NPIDeactivationReasonCode": null,
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"NPIReactivationDate": null,
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"AuthorizedOfficialLastName": "CARRASQUILLO",
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"AuthorizedOfficialCredential": "DMD",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "045010",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}