{
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"OrgName": "CENTER FOR ORAL AND MAXILLOFACIAL SURGERY, P.C.",
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"FirstLineMailingAddress": "10200 WEST MAIN",
"SecondLineMailingAddress": "SIGNAL HILL MEDICAL BLDG",
"MailingAddressCityName": "BELLEVILLE",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "62223",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "618-397-2464",
"MailingAddressFaxNumber": "618-398-4450",
"FirstLinePracticeLocationAddress": "10200 W MAIN ST",
"SecondLinePracticeLocationAddress": "SIGNAL HILL MEDICAL BLDG",
"PracticeLocationAddressCityName": "BELLEVILLE",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "62223-1408",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "618-397-2464",
"PracticeLocationAddressFaxNumber": "618-398-4450",
"EnumerationDate": "05/10/2007",
"LastUpdateDate": "06/03/2011",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MILLER",
"AuthorizedOfficialFirstName": "GLENN",
"AuthorizedOfficialMiddleName": "A",
"AuthorizedOfficialTitle": "ORAL & MAXILLOFACIAL SURGEON",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "DDS MS",
"AuthorizedOfficialTelephoneNumber": "618-387-2464",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "204E00000X",
"TaxonomyName": "Oral & Maxillofacial Surgery (D.M.D.)",
"LicenseNumber": "060000298",
"LicenseNumberStateCode": "IL",
"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."
}
}
}
}