{
"Npi": {
"NPI": "1821475831",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "GBCC DENTAL PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6708 S HULEN",
"SecondLineMailingAddress": "STE. 3",
"MailingAddressCityName": "FORT WORTH",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "76133",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "817-294-1090",
"MailingAddressFaxNumber": "903-465-1134",
"FirstLinePracticeLocationAddress": "6708 S HULEN",
"SecondLinePracticeLocationAddress": "STE. 3",
"PracticeLocationAddressCityName": "FORT WORTH",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "76133",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "817-294-1090",
"PracticeLocationAddressFaxNumber": "903-465-1134",
"EnumerationDate": "04/28/2015",
"LastUpdateDate": "09/28/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "COOK",
"AuthorizedOfficialFirstName": "CLAYTON",
"AuthorizedOfficialMiddleName": "K",
"AuthorizedOfficialTitle": "OWNER/DENTIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DMD",
"AuthorizedOfficialTelephoneNumber": "817-294-1090",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "29154",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}