{
"Npi": {
"NPI": "1437041225",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MJ SURGEON GROUP LLC",
"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": "625 W 57TH ST APT 2406",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "NEW YORK",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "10019-2687",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "646-455-8286",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "135 CHESTNUT RIDGE RD STE 1150",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MONTVALE",
"PracticeLocationAddressStateName": "NJ",
"PracticeLocationAddressPostalCode": "07645-1152",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "862-205-3056",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "07/17/2025",
"LastUpdateDate": "07/17/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KIM",
"AuthorizedOfficialFirstName": "JAY",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "ORAL & MAXILLOFACIAL SURGEON",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DMD",
"AuthorizedOfficialTelephoneNumber": "646-455-8286",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223S0112X",
"TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}