{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "BAYBROOK DENTAL GROUP",
"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": "31 WILLOWBROOK RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "QUEENSBURY",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "12804-5864",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "518-792-5103",
"MailingAddressFaxNumber": "518-792-5110",
"FirstLinePracticeLocationAddress": "31 WILLOWBROOK RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "QUEENSBURY",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "12804-5864",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "518-792-5103",
"PracticeLocationAddressFaxNumber": "518-792-5110",
"EnumerationDate": "05/09/2016",
"LastUpdateDate": "05/09/2016",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CANALE",
"AuthorizedOfficialFirstName": "GINA",
"AuthorizedOfficialMiddleName": "MARIE",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.M.D.",
"AuthorizedOfficialTelephoneNumber": "518-792-5103",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "044937",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X 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."
}
}
}
}