{
"Npi": {
"NPI": "1962938522",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "FAN",
"FirstName": "RAYMOND",
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": "DDS",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1600 S ANDREWS AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FORT LAUDERDALE",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33316-2510",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "954-459-2094",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "12860 10TH ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHINO",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91710-4294",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "909-591-0241",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/02/2017",
"LastUpdateDate": "10/18/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": "06/22/2018",
"NPIReactivationDate": "07/03/2018",
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "1223S0112X",
"TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
"LicenseNumber": "DD5682",
"LicenseNumberStateCode": "NM",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1223S0112X",
"TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
"LicenseNumber": "DDS104689",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
},
{
"TaxonomyCode": "390200000X",
"TaxonomyName": "Student in an Organized Health Care Education/Training Program",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}