{
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"FirstLineMailingAddress": "3030 LAKE AVE STE 15",
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"MailingAddressCityName": "FORT WAYNE",
"MailingAddressStateName": "IN",
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"MailingAddressCountryCode": "US",
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"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "3030 LAKE AVE STE 15",
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"EnumerationDate": "04/14/2026",
"LastUpdateDate": "04/14/2026",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FEASEL",
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"AuthorizedOfficialTitle": "DENTIST/OWNER",
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"AuthorizedOfficialCredential": "DDS",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
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"PrimaryTaxonomySwitch": "Y"
}
},
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}
}