{
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"OrgName": "CODIMS OF TAMPA BAY LLC",
"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6515 GUNN HWY",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "TAMPA",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33625-4021",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "813-968-5400",
"MailingAddressFaxNumber": "813-968-4433",
"FirstLinePracticeLocationAddress": "6515 GUNN HWY",
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"PracticeLocationAddressCityName": "TAMPA",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "813-968-5400",
"PracticeLocationAddressFaxNumber": "813-968-4433",
"EnumerationDate": "08/07/2007",
"LastUpdateDate": "08/20/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "VALIENTE",
"AuthorizedOfficialFirstName": "ERNESTO",
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"AuthorizedOfficialTitle": "GENERAL MANAGER",
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"AuthorizedOfficialCredential": "DMD",
"AuthorizedOfficialTelephoneNumber": "813-968-5400",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": "15074",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}