{
"Npi": {
"NPI": "1467734491",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BROCKTON DENTAL X-RAY LAB., INC.",
"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": "6800 BROCKTON AVE STE 3",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "RIVERSIDE",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92506-3810",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "951-682-7505",
"MailingAddressFaxNumber": "951-682-7549",
"FirstLinePracticeLocationAddress": "6800 BROCKTON AVE STE 3",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "RIVERSIDE",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "92506-3810",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "951-682-7505",
"PracticeLocationAddressFaxNumber": "951-682-7549",
"EnumerationDate": "09/15/2011",
"LastUpdateDate": "09/15/2011",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CARPENTER",
"AuthorizedOfficialFirstName": "MICHAEL",
"AuthorizedOfficialMiddleName": "W.",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "951-682-7505",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "292200000X",
"TaxonomyName": "Dental Laboratory",
"LicenseNumber": "RHP7971",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "292200000X",
"TaxonomyName": "Dental Laboratory",
"LicenseNumber": "RHP00050468",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}