Provider Demographics
NPI:1124364971
Name:ECONOMY DENTISTRY DUPONT STATION
Entity Type:Organization
Organization Name:ECONOMY DENTISTRY DUPONT STATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:POLITE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-714-6939
Mailing Address - Street 1:3615 DUPONT AVE
Mailing Address - Street 2:200-400
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2790
Mailing Address - Country:US
Mailing Address - Phone:904-714-6939
Mailing Address - Fax:904-751-9196
Practice Address - Street 1:3615 DUPONT AVE
Practice Address - Street 2:200-400
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2790
Practice Address - Country:US
Practice Address - Phone:904-714-6939
Practice Address - Fax:904-751-9196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN8243261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental