{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CAVITY REPAIR LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
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"OtherLastName": null,
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"OtherNamePrefix": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "557B JULIAN RIVERA",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CEIBA",
"MailingAddressStateName": "PR",
"MailingAddressPostalCode": "00735",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "787-885-0560",
"MailingAddressFaxNumber": "787-885-0560",
"FirstLinePracticeLocationAddress": "557B CALLE JULIAN RIVERA",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CEIBA",
"PracticeLocationAddressStateName": "PR",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "787-885-0560",
"PracticeLocationAddressFaxNumber": "787-885-0560",
"EnumerationDate": "09/22/2015",
"LastUpdateDate": "09/22/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LAFONTAINE",
"AuthorizedOfficialFirstName": "EDWIN",
"AuthorizedOfficialMiddleName": "E",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "787-515-7036",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": "2080",
"LicenseNumberStateCode": "PR",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}