Provider Demographics
NPI:1578732962
Name:ECONOMY DENTURES
Entity Type:Organization
Organization Name:ECONOMY DENTURES
Other - Org Name:ECONOMY DENTURES OF SO DAYTONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:D.M.D
Authorized Official - Prefix:DR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:R
Authorized Official - Last Name:POLITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-761-9681
Mailing Address - Street 1:2400 SOUTH RIDGEWOOD AVE #10B
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-3097
Mailing Address - Country:US
Mailing Address - Phone:386-761-9681
Mailing Address - Fax:386-761-9107
Practice Address - Street 1:2400 S RIDGEWOOD AVE STE 10B
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-5005
Practice Address - Country:US
Practice Address - Phone:386-761-9681
Practice Address - Fax:386-761-9107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ECONOMY DENTURES OF SO DAYTONA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-29
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10854122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076873100Medicaid