{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "KATHLEEN ELLSWORTH DDS PC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
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"Credential": null,
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"OtherLastName": null,
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"OtherNamePrefix": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 70",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SARANAC",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48881-0070",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "616-642-3500",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "60 N BRIDGE ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SARANAC",
"PracticeLocationAddressStateName": "MI",
"PracticeLocationAddressPostalCode": "48881-5109",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "616-642-3500",
"PracticeLocationAddressFaxNumber": "616-642-3600",
"EnumerationDate": "04/06/2022",
"LastUpdateDate": "04/07/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ELLSWORTH",
"AuthorizedOfficialFirstName": "KATHLEEN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "DENTIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "616-642-3500",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}