Provider Demographics
NPI:1790246411
Name:ECONOMY DENTISTRY FOR CHILDREN - DUPONT STATION, LLC
Entity Type:Organization
Organization Name:ECONOMY DENTISTRY FOR CHILDREN - DUPONT STATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:R
Authorized Official - Last Name:POLITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-683-1769
Mailing Address - Street 1:3615 DUPONT AVE STE 200-400
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2790
Mailing Address - Country:US
Mailing Address - Phone:904-683-1769
Mailing Address - Fax:904-900-1243
Practice Address - Street 1:1319 E OSCEOLA PKWY STE C
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1606
Practice Address - Country:US
Practice Address - Phone:904-683-1769
Practice Address - Fax:904-900-1243
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ECONOMY DENTISTRY FOR CHILDREN - DUPONT STATION, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-26
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental