{
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"IsOrgSubpart": "N",
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"OrgName": "LAKE AREA DENTAL",
"LastName": null,
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"OtherLastName": null,
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"FirstLineMailingAddress": "140 WILDWOOD CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MAHTOMEDI",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55115-4200",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "651-308-1177",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "4801 HIGHWAY 61 N STE 301",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "WHITE BEAR LAKE",
"PracticeLocationAddressStateName": "MN",
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"PracticeLocationAddressTelephoneNumber": "651-762-8474",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "12/05/2024",
"LastUpdateDate": "12/05/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DITTBERNER",
"AuthorizedOfficialFirstName": "JORDAN",
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"AuthorizedOfficialTitle": "DENTIST",
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"AuthorizedOfficialCredential": "DDS",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
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"PrimaryTaxonomySwitch": "Y"
}
},
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}
}