{
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"EIN": null,
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"OrgName": "UNIVERSAL DENTAL PA",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
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"OtherLastName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "209 EAST CROSSTIMBERS RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "HOUSTON",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "77022",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "713-692-1344",
"MailingAddressFaxNumber": "713-692-8141",
"FirstLinePracticeLocationAddress": "209 EAST CROSSTIMBERS RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "HOUSTON",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "77022",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "713-692-1344",
"PracticeLocationAddressFaxNumber": "713-692-8141",
"EnumerationDate": "10/12/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LEVISON",
"AuthorizedOfficialFirstName": "JEONG",
"AuthorizedOfficialMiddleName": "S",
"AuthorizedOfficialTitle": "PRESIDENT",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "713-692-1344",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "19106",
"LicenseNumberStateCode": "TX",
"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."
}
}
}
}