{
"Npi": {
"NPI": "1417110537",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "KRYSTAL CLEAR DENTAL P.L.",
"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": "18838 DUQUESNE DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "TAMPA",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33647-3421",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "813-849-3695",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "19445 SHUMARD OAK DR",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "LAND O LAKES",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "34638-7262",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "813-849-3695",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "07/09/2008",
"LastUpdateDate": "07/09/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DUVERT",
"AuthorizedOfficialFirstName": "KRYSTELLE",
"AuthorizedOfficialMiddleName": "TERRY",
"AuthorizedOfficialTitle": "DENTIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "813-849-3695",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "16987",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}