Provider Demographics
NPI:1750588133
Name:ECONOMY DENTURES
Entity type:Organization
Organization Name:ECONOMY DENTURES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
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:DMD
Authorized Official - Phone:904-696-6767
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:904-696-6767
Practice Address - Street 1:1680 DUNN AVE STE 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:904-696-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN8243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076491400Medicaid
FL076637200Medicaid
FL073760700Medicaid