{
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"IsOrgSubpart": "N",
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"FirstLineMailingAddress": "4847 HIGH MEADOWS DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GROVETOWN",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30813-8103",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "912-389-0638",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "444 N BELAIR RD STE 101",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "EVANS",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30809-3002",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "762-218-2186",
"PracticeLocationAddressFaxNumber": "762-200-2302",
"EnumerationDate": "12/04/2023",
"LastUpdateDate": "03/20/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BOOKOUT",
"AuthorizedOfficialFirstName": "JONATHAN",
"AuthorizedOfficialMiddleName": "KEITH",
"AuthorizedOfficialTitle": "OWNER/DENTIST",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "DMD",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223G0001X",
"TaxonomyName": "General Practice Dentistry",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}