{
"Npi": {
"NPI": "1699200220",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "FARWEST 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": "1704 N AVALON BLVD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WILMINGTON",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "90744-1433",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "310-835-5130",
"MailingAddressFaxNumber": "310-835-6090",
"FirstLinePracticeLocationAddress": "1704 N AVALON BLVD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "WILMINGTON",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "90744-1433",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "310-835-5130",
"PracticeLocationAddressFaxNumber": "310-835-6090",
"EnumerationDate": "04/20/2017",
"LastUpdateDate": "04/20/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FAYOUMI",
"AuthorizedOfficialFirstName": "HASSAN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "ONWER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "310-699-1549",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "52604",
"LicenseNumberStateCode": "CA",
"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."
}
}
}
}