{
"Npi": {
"NPI": "1548730450",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MASTOUR & FARD DENTAL CORP",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "5620 SAWTELLE BLVD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CULVER CITY",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "90230-5508",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "310-390-6212",
"MailingAddressFaxNumber": "310-390-6215",
"FirstLinePracticeLocationAddress": "587 N. VENTU PARK ROAD.",
"SecondLinePracticeLocationAddress": "SUITE C",
"PracticeLocationAddressCityName": "NEWBERRY PARK",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91320",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "805-499-1253",
"PracticeLocationAddressFaxNumber": "805-499-1453",
"EnumerationDate": "12/04/2018",
"LastUpdateDate": "10/23/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MASTOUR",
"AuthorizedOfficialFirstName": "PEDRAM",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "310-804-0414",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "305R00000X",
"TaxonomyName": "Preferred Provider Organization",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}