{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "MOUTHPEACE DENTAL 4, LLC",
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"FirstName": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2149 BRANNEN RD SE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ATLANTA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30316-4117",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "312-371-1423",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "541 FOREST PKWY STE 18",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "FOREST PARK",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30297-6110",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "404-228-6801",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/14/2020",
"LastUpdateDate": "04/14/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WELLS",
"AuthorizedOfficialFirstName": "SYRETTA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER /DENTIST",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "312-371-1423",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}