{
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"FirstLineMailingAddress": "34225 N 27TH DRIVE",
"SecondLineMailingAddress": "BLDG 5 SUITE 241",
"MailingAddressCityName": "PHOENIX",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "85085-6091",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "623-439-2280",
"MailingAddressFaxNumber": "623-289-2578",
"FirstLinePracticeLocationAddress": "1751 STOCKTON HILL RD",
"SecondLinePracticeLocationAddress": "STE A",
"PracticeLocationAddressCityName": "KINGMAN",
"PracticeLocationAddressStateName": "AZ",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "928-718-8668",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "10/29/2018",
"LastUpdateDate": "05/03/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "RAMA",
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"AuthorizedOfficialTitle": "MANAGER",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "623-208-7982",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"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."
}
}
}
}