{
"Npi": {
"NPI": "1699042655",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "MITCHELL",
"FirstName": "SUSANNAH",
"MiddleName": "MARTHA",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "DMD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "3164 JUNCTION HWY STE W-1",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "INGRAM",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "78025-3194",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "830-367-1171",
"MailingAddressFaxNumber": "830-367-1173",
"FirstLinePracticeLocationAddress": "3164 JUNCTION HWY STE W-1",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "INGRAM",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "78025-3194",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "830-367-1171",
"PracticeLocationAddressFaxNumber": "830-367-1173",
"EnumerationDate": "11/18/2011",
"LastUpdateDate": "04/22/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "9121",
"LicenseNumberStateCode": "KY",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "24179",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "10704",
"LicenseNumberStateCode": "CO",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": "31661",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}