{
"Npi": {
"NPI": "1770609000",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "COSMETIC FAMILY DENTAL CLINIC PC",
"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": "1236 E BASELINE RD",
"SecondLineMailingAddress": "#103",
"MailingAddressCityName": "MESA",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "85204-6705",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "480-503-3600",
"MailingAddressFaxNumber": "480-503-3601",
"FirstLinePracticeLocationAddress": "1236 E BASELINE RD",
"SecondLinePracticeLocationAddress": "#103",
"PracticeLocationAddressCityName": "MESA",
"PracticeLocationAddressStateName": "AZ",
"PracticeLocationAddressPostalCode": "85204-6705",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "480-503-3600",
"PracticeLocationAddressFaxNumber": "480-503-3601",
"EnumerationDate": "03/21/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HUYNH",
"AuthorizedOfficialFirstName": "NICK",
"AuthorizedOfficialMiddleName": "NAM",
"AuthorizedOfficialTitle": "OWNER DENTIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "480-503-3600",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "5118",
"LicenseNumberStateCode": "AZ",
"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."
}
}
}
}