{
"Npi": {
"NPI": "1386412328",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "ADVANTAGE DENTAL ORAL HEALTH CENTER OF OKLAHOMA, P.C.",
"ParentOrgTIN": null,
"OrgName": "ADVANTAGE DENTAL ORAL HEALTH CENTER OF OKLAHOMA, P.C.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "63140 BRITTA ST STE D104",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BEND",
"MailingAddressStateName": "OR",
"MailingAddressPostalCode": "97703-5738",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "629-999-5014",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2619 S ELM PL",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "BROKEN ARROW",
"PracticeLocationAddressStateName": "OK",
"PracticeLocationAddressPostalCode": "74012-7878",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "918-872-0218",
"PracticeLocationAddressFaxNumber": "918-872-0892",
"EnumerationDate": "12/19/2023",
"LastUpdateDate": "03/19/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "EDMONDSON",
"AuthorizedOfficialFirstName": "SHERRIE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "SR MANAGER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "629-999-5014",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223P0221X",
"TaxonomyName": "Pediatric Dentistry",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223S0112X",
"TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"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."
},
{
"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."
},
{
"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."
},
{
"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."
}
]
}
}
}