{
"Npi": {
"NPI": "1619311198",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BOLD DENTAL PARTNERS PLLC",
"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": "PO BOX 1108",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FAYETTEVILLE",
"MailingAddressStateName": "AR",
"MailingAddressPostalCode": "72702-1108",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "479-439-9192",
"MailingAddressFaxNumber": "479-725-2395",
"FirstLinePracticeLocationAddress": "640 N GARLAND AVE",
"SecondLinePracticeLocationAddress": "SUITE 104",
"PracticeLocationAddressCityName": "FAYETTEVILLE",
"PracticeLocationAddressStateName": "AR",
"PracticeLocationAddressPostalCode": "72701",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "479-521-2653",
"PracticeLocationAddressFaxNumber": "479-575-0380",
"EnumerationDate": "04/26/2013",
"LastUpdateDate": "08/28/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BOLDING",
"AuthorizedOfficialFirstName": "SCOTT",
"AuthorizedOfficialMiddleName": "L",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "479-521-2653",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "3062",
"LicenseNumberStateCode": "AR",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}