Provider Demographics
NPI:1225317423
Name:ECONOMY DENTISTRY FOR CHILDREN CHILDREN'S GENERAL DENTISTRY , LLC
Entity Type:Organization
Organization Name:ECONOMY DENTISTRY FOR CHILDREN CHILDREN'S GENERAL DENTISTRY , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:R
Authorized Official - Last Name:POLITE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-714-6939
Mailing Address - Street 1:1680 DUNN AVE
Mailing Address - Street 2:#31
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4782
Mailing Address - Country:US
Mailing Address - Phone:904-696-6767
Mailing Address - Fax:904-696-6833
Practice Address - Street 1:1680 DUNN AVE
Practice Address - Street 2:#31
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4782
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:2011-08-05
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN82431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty