{
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"FirstLineMailingAddress": "6803 DIXIE HWY STE 1",
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"MailingAddressCityName": "CLARKSTON",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "248-625-1721",
"MailingAddressFaxNumber": "248-625-5475",
"FirstLinePracticeLocationAddress": "6803 DIXIE HWY STE 1",
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"PracticeLocationAddressTelephoneNumber": "248-625-1721",
"PracticeLocationAddressFaxNumber": "248-625-5475",
"EnumerationDate": "01/22/2008",
"LastUpdateDate": "04/25/2022",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BOUTROS",
"AuthorizedOfficialFirstName": "SUHEIL",
"AuthorizedOfficialMiddleName": "MICHAEL",
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"AuthorizedOfficialCredential": "DDS,MS",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Periodontics",
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}
},
"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."
}
}
}
}