{
"Npi": {
"NPI": "1790474880",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "NICHOLAS GOULTAS, DDS, 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": "1831 POLK ST APT 107",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SAN FRANCISCO",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "94109-3013",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "650-703-7451",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "5011 GEARY BLVD STE A",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SAN FRANCISCO",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "94118-2880",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "650-703-7451",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/04/2023",
"LastUpdateDate": "05/04/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GOULTAS",
"AuthorizedOfficialFirstName": "NICHOLAS",
"AuthorizedOfficialMiddleName": "GEORGE",
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "DDS, MPH",
"AuthorizedOfficialTelephoneNumber": "650-703-7451",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}