{
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"NamePrefix": null,
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"FirstLineMailingAddress": "6315 PEARL RD STE 201",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PARMA HEIGHTS",
"MailingAddressStateName": "OH",
"MailingAddressPostalCode": "44130-3074",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "440-345-9068",
"MailingAddressFaxNumber": "440-842-4612",
"FirstLinePracticeLocationAddress": "667 CHESTNUT COMMONS DRIVE",
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"PracticeLocationAddressCityName": "ELYRIA",
"PracticeLocationAddressStateName": "OH",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "440-324-2310",
"PracticeLocationAddressFaxNumber": "440-324-9454",
"EnumerationDate": "12/20/2007",
"LastUpdateDate": "05/18/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ULICHNEY",
"AuthorizedOfficialFirstName": "DIANE",
"AuthorizedOfficialMiddleName": "L",
"AuthorizedOfficialTitle": "CREDENTIALING MANAGER",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "440-345-9068",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Dentist",
"LicenseNumber": "19758",
"LicenseNumberStateCode": "OH",
"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."
}
}
}
}