{
"Npi": {
"NPI": "1861930430",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "FORD DENTAL LAB INC",
"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": "2828 NW 57TH ST STE 307",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "OKLAHOMA CITY",
"MailingAddressStateName": "OK",
"MailingAddressPostalCode": "73112",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "405-795-3169",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2828 NW 57TH ST",
"SecondLinePracticeLocationAddress": "307",
"PracticeLocationAddressCityName": "OKLAHOMA CITY",
"PracticeLocationAddressStateName": "OK",
"PracticeLocationAddressPostalCode": "73112-6814",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "405-887-0502",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "02/03/2017",
"LastUpdateDate": "02/03/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "STOLBACH",
"AuthorizedOfficialFirstName": "VICTOR",
"AuthorizedOfficialMiddleName": "LEON",
"AuthorizedOfficialTitle": "PARTNER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "405-887-0502",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "292200000X",
"TaxonomyName": "Dental Laboratory",
"LicenseNumber": "DL65",
"LicenseNumberStateCode": "OK",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}