Provider Demographics
NPI:1629211735
Name:ECONOMY DENTURES OF LAKE MARY
Entity Type:Organization
Organization Name:ECONOMY DENTURES OF LAKE MARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:KIMBRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-696-6767
Mailing Address - Street 1:1680 DUNN AVE
Mailing Address - Street 2:SUITE 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:
Practice Address - Street 1:890 S SUN DR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2406
Practice Address - Country:US
Practice Address - Phone:407-333-3508
Practice Address - Fax:407-804-5189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ECONOMY DENTURES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN82431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty