{
"Npi": {
"NPI": "1760667091",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MENDOTA DENTAL ASSOCIATES",
"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": "720 MAIN ST",
"SecondLineMailingAddress": "SUITE 213",
"MailingAddressCityName": "MENDOTA HEIGHTS",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55118-3757",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "651-454-1502",
"MailingAddressFaxNumber": "651-454-1504",
"FirstLinePracticeLocationAddress": "720 MAIN ST",
"SecondLinePracticeLocationAddress": "SUITE 213",
"PracticeLocationAddressCityName": "MENDOTA HEIGHTS",
"PracticeLocationAddressStateName": "MN",
"PracticeLocationAddressPostalCode": "55118-3757",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "651-454-1502",
"PracticeLocationAddressFaxNumber": "651-454-1504",
"EnumerationDate": "01/06/2008",
"LastUpdateDate": "01/06/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MALLINGER",
"AuthorizedOfficialFirstName": "MICHAEL",
"AuthorizedOfficialMiddleName": "D",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "763-226-1784",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "D9530",
"LicenseNumberStateCode": "MN",
"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."
}
}
}
}