{
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"EIN": null,
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"IsOrgSubpart": "N",
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"LastName": null,
"FirstName": null,
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"NamePrefix": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "302 ROYAL PKWY",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "DOTHAN",
"MailingAddressStateName": "AL",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "334-661-7671",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2001 ALEXANDER DR",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DOTHAN",
"PracticeLocationAddressStateName": "AL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "334-794-0348",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/14/2023",
"LastUpdateDate": "03/14/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "HAYNIE",
"AuthorizedOfficialFirstName": "CARL",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": "III",
"AuthorizedOfficialCredential": "MBA",
"AuthorizedOfficialTelephoneNumber": "334-661-7671",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}