{
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"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "PARKWAY DENTAL, SC",
"SecondLineMailingAddress": "2901 W KINNIC KINNIC RIVER PARKWAY, STE 104",
"MailingAddressCityName": "MILWAUKEE",
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"MailingAddressPostalCode": "53215",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "414-649-3510",
"MailingAddressFaxNumber": "414-385-2854",
"FirstLinePracticeLocationAddress": "G DENTAL, LLC",
"SecondLinePracticeLocationAddress": "7635 W BLUEMOUND RD, STE 208",
"PracticeLocationAddressCityName": "MILWAUKEE",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "414-258-6330",
"PracticeLocationAddressFaxNumber": "414-258-3622",
"EnumerationDate": "02/24/2026",
"LastUpdateDate": "02/24/2026",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GEQUILLANA",
"AuthorizedOfficialFirstName": "GLENN",
"AuthorizedOfficialMiddleName": "DE LA LLANZ",
"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialCredential": "DDS",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
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"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}