{
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"OrgName": "ELY FAMILY DENTISTRY",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "40 N 1ST AVE E",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ELY",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55731",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "218-365-3145",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "40 N 1ST AVE E",
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"PracticeLocationAddressCityName": "ELY",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "218-365-3145",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "01/22/2009",
"LastUpdateDate": "01/22/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BEERS",
"AuthorizedOfficialFirstName": "DAVID",
"AuthorizedOfficialMiddleName": "J",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DDS",
"AuthorizedOfficialTelephoneNumber": "218-365-3145",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "122300000X",
"TaxonomyName": "Dentist",
"LicenseNumber": "9638",
"LicenseNumberStateCode": "MN",
"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."
}
}
}
}