{
"Npi": {
"NPI": "1992806335",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CAROLINA DENTURES & DENTISTRY",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
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"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 538",
"SecondLineMailingAddress": "10701 US HWY 41 NORTH DUNNELLON",
"MailingAddressCityName": "DUNNELLON",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "34432",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "352-489-0707",
"MailingAddressFaxNumber": "352-489-1525",
"FirstLinePracticeLocationAddress": "10701 US HWY 41 NORTH DUNNELLON",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DUNNELLON",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "34432",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "352-489-0707",
"PracticeLocationAddressFaxNumber": "352-489-1525",
"EnumerationDate": "09/26/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GONZALEZ",
"AuthorizedOfficialFirstName": "REYNALDO",
"AuthorizedOfficialMiddleName": "FAVALA",
"AuthorizedOfficialTitle": "OWNER OPERATOR",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DMD",
"AuthorizedOfficialTelephoneNumber": "352-489-0707",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": "DN0011269",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}