{
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"FirstLineMailingAddress": "5700 SE 89TH ST",
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"MailingAddressStateName": "OK",
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"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "3001 S TELEPHONE RD",
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"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "08/14/2023",
"LastUpdateDate": "08/14/2023",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ISRAELSEN",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "361-405-9080",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}