{
"Npi": {
"NPI": "1962147686",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "JACKSONVILLE EMERGENCY DENTAL NORTH, PLLC",
"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": "789 MILL STREAM RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PONTE VEDRA BEACH",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32082-4148",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "904-891-6691",
"MailingAddressFaxNumber": "904-263-4560",
"FirstLinePracticeLocationAddress": "1840 DUNN AVE STE 3",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "JACKSONVILLE",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32218-4785",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "904-224-0046",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/28/2022",
"LastUpdateDate": "04/28/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "THOMASINO",
"AuthorizedOfficialFirstName": "MICHAEL",
"AuthorizedOfficialMiddleName": "JAMES",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DMD",
"AuthorizedOfficialTelephoneNumber": "904-891-6691",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"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."
}
}
}
}