{
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"OrgName": "KELLY M. GONZALES, DDS, PC",
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"FirstLineMailingAddress": "1103 RIVERY BLVD",
"SecondLineMailingAddress": "STE 140",
"MailingAddressCityName": "GEORGETOWN",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "78628-3034",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "512-864-9595",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1103 RIVERY BLVD",
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"PracticeLocationAddressCityName": "GEORGETOWN",
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"PracticeLocationAddressTelephoneNumber": "512-864-9595",
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"EnumerationDate": "04/14/2008",
"LastUpdateDate": "09/23/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GONZALES",
"AuthorizedOfficialFirstName": "KELLY",
"AuthorizedOfficialMiddleName": "MARIE",
"AuthorizedOfficialTitle": "PRESIDENT",
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"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "512-864-9595",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223P0221X",
"TaxonomyName": "Pediatric Dentistry",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"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."
}
}
}
}