{
"Npi": {
"NPI": "1770981763",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PEACHTREE DUNWOODY ORAL AND FACIAL SURGERY",
"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": "5505 PEACHTREE DUNWOODY RD",
"SecondLineMailingAddress": "SUITE 660",
"MailingAddressCityName": "ATLANTA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30342-1705",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "404-220-7505",
"MailingAddressFaxNumber": "404-220-7506",
"FirstLinePracticeLocationAddress": "5505 PEACHTREE DUNWOODY RD",
"SecondLinePracticeLocationAddress": "SUITE 660",
"PracticeLocationAddressCityName": "ATLANTA",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30342-1705",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "404-220-7505",
"PracticeLocationAddressFaxNumber": "404-220-7506",
"EnumerationDate": "12/08/2014",
"LastUpdateDate": "12/08/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "IVERSON",
"AuthorizedOfficialFirstName": "IRENE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "INSURANCE ADMINISTRATOR",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "404-220-7505",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223S0112X",
"TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
"LicenseNumber": "DN010345",
"LicenseNumberStateCode": "GA",
"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."
}
}
}
}