{
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"IsOrgSubpart": "N",
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"FirstLineMailingAddress": "9309 OFFICE PARK CIR STE 120",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ELK GROVE",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "95758-8072",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "916-691-1050",
"MailingAddressFaxNumber": "916-691-1066",
"FirstLinePracticeLocationAddress": "2535 E BIDWELL ST STE 150",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "FOLSOM",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "95630-6458",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "916-984-1109",
"PracticeLocationAddressFaxNumber": "916-984-1764",
"EnumerationDate": "09/09/2009",
"LastUpdateDate": "09/09/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BLAKE",
"AuthorizedOfficialFirstName": "RENEE",
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"AuthorizedOfficialTitle": "INSURANCE SPECIALIST",
"AuthorizedOfficialNamePrefix": "MRS.",
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"AuthorizedOfficialTelephoneNumber": "916-691-1050",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1223P0300X",
"TaxonomyName": "Periodontics",
"LicenseNumber": "22639744",
"LicenseNumberStateCode": "CA",
"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."
}
}
}
}