{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "MEDINA & OLIVA DENTAL PC",
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"MiddleName": null,
"NamePrefix": null,
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"FirstLineMailingAddress": "1932 BELGRAVE DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PETALUMA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "94954-3995",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "425-647-0907",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "925 CORPORATE CNTR PKWY STE G",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SANTA ROSA",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "95407-5453",
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"PracticeLocationAddressTelephoneNumber": "425-647-0907",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "12/16/2018",
"LastUpdateDate": "12/16/2018",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MEDINA",
"AuthorizedOfficialFirstName": "DAVID",
"AuthorizedOfficialMiddleName": "ALEJANDRO",
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"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "425-647-0907",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}