{
"Npi": {
"NPI": "1619354693",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MONTGOMERY COMPREHENSIVE DENTAL CENTER",
"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": "0951 LONESTAR PARKWAY",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MONTGOMERY",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "77356-0951",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "936-230-5445",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2210 N FRAZIER ST",
"SecondLinePracticeLocationAddress": "SUITE #120",
"PracticeLocationAddressCityName": "CONROE",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "77303-1780",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "936-539-3636",
"PracticeLocationAddressFaxNumber": "936-539-3639",
"EnumerationDate": "04/29/2015",
"LastUpdateDate": "04/29/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "STARK",
"AuthorizedOfficialFirstName": "RACHEL",
"AuthorizedOfficialMiddleName": "D",
"AuthorizedOfficialTitle": "FINANCIAL COORDINATOR",
"AuthorizedOfficialNamePrefix": "MISS",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "936-539-3636",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "302F00000X",
"TaxonomyName": "Exclusive Provider Organization",
"LicenseNumber": "16499",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}