{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "MUNOZ, FORBES, SOUZA, LEE, KANO & CONLEY A DENTAL CORP.",
"LastName": null,
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"NamePrefix": null,
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"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
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"FirstLineMailingAddress": "909 W ROSEBURG AVE STE A",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MODESTO",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "95350-5062",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "209-526-3815",
"MailingAddressFaxNumber": "209-579-9521",
"FirstLinePracticeLocationAddress": "529 E CENTER ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MANTECA",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "95336-4719",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "209-526-3815",
"PracticeLocationAddressFaxNumber": "209-579-9521",
"EnumerationDate": "03/30/2009",
"LastUpdateDate": "03/30/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CONLEY",
"AuthorizedOfficialFirstName": "JAMES",
"AuthorizedOfficialMiddleName": "A",
"AuthorizedOfficialTitle": "SECRETARY",
"AuthorizedOfficialNamePrefix": "MR.",
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"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "209-526-3815",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "43926",
"LicenseNumberStateCode": "CA",
"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."
}
}
}
}