Provider Demographics
NPI:1740383017
Name:POLITE, LEROY R (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:R
Last Name:POLITE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 DUNN AVE STE 31
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4744
Mailing Address - Country:US
Mailing Address - Phone:904-696-6767
Mailing Address - Fax:904-696-6833
Practice Address - Street 1:1680 DUNN AVNUE SUITE# 31
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4744
Practice Address - Country:US
Practice Address - Phone:904-696-6767
Practice Address - Fax:904-696-6833
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN82431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice