{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "GRAND RIVER ENDODONTICS PC",
"LastName": null,
"FirstName": null,
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"NamePrefix": null,
"NameSuffix": null,
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"OtherOrgName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "4211 PARKWAY PLACE DR SW",
"SecondLineMailingAddress": "SUITE 104",
"MailingAddressCityName": "GRANDVILLE",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "49418-2695",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "616-249-3500",
"MailingAddressFaxNumber": "616-249-3502",
"FirstLinePracticeLocationAddress": "4211 PARKWAY PLACE DR SW",
"SecondLinePracticeLocationAddress": "SUITE 104",
"PracticeLocationAddressCityName": "GRANDVILLE",
"PracticeLocationAddressStateName": "MI",
"PracticeLocationAddressPostalCode": "49418-2695",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "616-249-3500",
"PracticeLocationAddressFaxNumber": "616-249-3502",
"EnumerationDate": "10/07/2014",
"LastUpdateDate": "09/30/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": "10/21/2014",
"NPIReactivationDate": "09/30/2017",
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MASTERSON",
"AuthorizedOfficialFirstName": "SARAH",
"AuthorizedOfficialMiddleName": "LENNAN",
"AuthorizedOfficialTitle": "OWNER/ENDODONTIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS, MSD",
"AuthorizedOfficialTelephoneNumber": "616-249-3500",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223E0200X",
"TaxonomyName": "Endodontics",
"LicenseNumber": "2901019457",
"LicenseNumberStateCode": "MI",
"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."
}
}
}
}