{
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"FirstLineMailingAddress": "PO BOX 330874",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FORT WORTH",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "76163-0874",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "817-370-0268",
"MailingAddressFaxNumber": "817-263-9217",
"FirstLinePracticeLocationAddress": "3060 SYCAMORE SCHOOL RD",
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"PracticeLocationAddressCityName": "FORT WORTH",
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"PracticeLocationAddressFaxNumber": "817-263-9217",
"EnumerationDate": "12/11/2006",
"LastUpdateDate": "10/12/2008",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BIRTH",
"AuthorizedOfficialFirstName": "SHEILA",
"AuthorizedOfficialMiddleName": "T.",
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"AuthorizedOfficialCredential": "DDS, MS",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223X0400X",
"TaxonomyName": "Orthodontics and Dentofacial Orthopedics Dentistry",
"LicenseNumber": "14150",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}