{
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"IsOrgSubpart": "N",
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"LastName": null,
"FirstName": null,
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"FirstLineMailingAddress": "73501 WINDMILL DR",
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"MailingAddressCityName": "BRUCE TWP",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48065-3159",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "34301 23 MILE RD STE 140A",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHESTERFIELD",
"PracticeLocationAddressStateName": "MI",
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"PracticeLocationAddressTelephoneNumber": "586-725-5500",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "01/25/2022",
"LastUpdateDate": "01/25/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "VAN DE VYVER",
"AuthorizedOfficialFirstName": "SHAWN",
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"AuthorizedOfficialTitle": "MANAGER",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "734-320-8939",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}