{
"Npi": {
"NPI": "1679745269",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "FAMLIY DENTAL HEALTH CENTER",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "200 N WOODRUFF AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "IDAHO FALLS",
"MailingAddressStateName": "ID",
"MailingAddressPostalCode": "83401-4334",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "208-529-0120",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "200 N WOODRUFF AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "IDAHO FALLS",
"PracticeLocationAddressStateName": "ID",
"PracticeLocationAddressPostalCode": "83401-4334",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "208-529-0120",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/24/2008",
"LastUpdateDate": "06/19/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "STALEY",
"AuthorizedOfficialFirstName": "GALEN",
"AuthorizedOfficialMiddleName": "JAY",
"AuthorizedOfficialTitle": "PARTNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "208-529-0120",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "D1628",
"LicenseNumberStateCode": "ID",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "D3614",
"LicenseNumberStateCode": "ID",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "D3038",
"LicenseNumberStateCode": "ID",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "D3064",
"LicenseNumberStateCode": "ID",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
]
}
}
}