{
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"OrgName": "ORAL AND MAXILLOFACIAL SURGERY ASSOCIATE OF NEW MEXICO, P.A.",
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"FirstLineMailingAddress": "6800 MONTGOMERY BLVD NE",
"SecondLineMailingAddress": "SUITE A",
"MailingAddressCityName": "ALBUQUERQUE",
"MailingAddressStateName": "NM",
"MailingAddressPostalCode": "87109-1405",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "505-881-1130",
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"FirstLinePracticeLocationAddress": "6800 MONTGOMERY BLVD NE",
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"PracticeLocationAddressCountryCode": "US",
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"EnumerationDate": "05/31/2007",
"LastUpdateDate": "07/08/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MITCHELL",
"AuthorizedOfficialFirstName": "JOHN",
"AuthorizedOfficialMiddleName": "C",
"AuthorizedOfficialTitle": "MANAGING PARTNER",
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"AuthorizedOfficialCredential": "D.D.S.",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223S0112X",
"TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
"LicenseNumber": "02-256180-00-3",
"LicenseNumberStateCode": "NM",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE 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."
}
}
}
}