{
"Npi": {
"NPI": "1588091250",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "ST. LUKE'S DENTAL, PLC.",
"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": "1908 LAND O LAKES BLVD",
"SecondLineMailingAddress": "SUITE 3",
"MailingAddressCityName": "LUTZ",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33549-2914",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "813-909-1555",
"MailingAddressFaxNumber": "813-909-1556",
"FirstLinePracticeLocationAddress": "1908 LAND O LAKES BLVD",
"SecondLinePracticeLocationAddress": "SUITE 3",
"PracticeLocationAddressCityName": "LUTZ",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "33549-2914",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "813-909-1555",
"PracticeLocationAddressFaxNumber": "813-909-1556",
"EnumerationDate": "09/26/2013",
"LastUpdateDate": "09/26/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WAHBA",
"AuthorizedOfficialFirstName": "DANIEL",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "813-909-1555",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": "DN15339",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}