{
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"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MILL CREEK ORAL & MAXILLOFACIAL SURGERY ASSOCIATES INC",
"LastName": null,
"FirstName": null,
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"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
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"OtherMiddleName": null,
"OtherNamePrefix": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "5437 MAHONING AVE",
"SecondLineMailingAddress": "SUITE 12",
"MailingAddressCityName": "AUSTINTOWN",
"MailingAddressStateName": "OH",
"MailingAddressPostalCode": "44515-2437",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "330-792-2501",
"MailingAddressFaxNumber": "330-792-9249",
"FirstLinePracticeLocationAddress": "5437 MAHONING AVE STE 12",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "AUSTINTOWN",
"PracticeLocationAddressStateName": "OH",
"PracticeLocationAddressPostalCode": "44515-2421",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "330-792-2501",
"PracticeLocationAddressFaxNumber": "330-792-9249",
"EnumerationDate": "02/27/2007",
"LastUpdateDate": "01/23/2012",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BILLY",
"AuthorizedOfficialFirstName": "MARK",
"AuthorizedOfficialMiddleName": "L",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.D.S.",
"AuthorizedOfficialTelephoneNumber": "330-792-2501",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "204E00000X",
"TaxonomyName": "Oral & Maxillofacial Surgery (D.M.D.)",
"LicenseNumber": "204E0000X",
"LicenseNumberStateCode": "OH",
"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."
}
}
}
}