{
"Npi": {
"NPI": "1518172113",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "JUAN COLLADO, DDS PC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
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"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "365 ROCKLEDGE PL",
"SecondLineMailingAddress": "PRIVATE HOUSE",
"MailingAddressCityName": "TEANECK",
"MailingAddressStateName": "NJ",
"MailingAddressPostalCode": "07666-4014",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "212-568-3231",
"MailingAddressFaxNumber": "212-568-7727",
"FirstLinePracticeLocationAddress": "520 W 190TH ST",
"SecondLinePracticeLocationAddress": "SUITE A",
"PracticeLocationAddressCityName": "NEW YORK",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "10040-3407",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "212-568-3231",
"PracticeLocationAddressFaxNumber": "212-568-7727",
"EnumerationDate": "05/14/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "COLLADO",
"AuthorizedOfficialFirstName": "JUAN",
"AuthorizedOfficialMiddleName": "PABLO",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.D.S.",
"AuthorizedOfficialTelephoneNumber": "212-568-3231",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "045828-1",
"LicenseNumberStateCode": "NY",
"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."
}
}
}
}