Healthcare Provider Details

I. General information

NPI: 1790246411
Provider Name (Legal Business Name): ECONOMY DENTISTRY FOR CHILDREN - DUPONT STATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 E OSCEOLA PKWY STE C
KISSIMMEE FL
34744-1606
US

IV. Provider business mailing address

3615 DUPONT AVE STE 200-400
JACKSONVILLE FL
32217-2790
US

V. Phone/Fax

Practice location:
  • Phone: 904-683-1769
  • Fax: 904-900-1243
Mailing address:
  • Phone: 904-683-1769
  • Fax: 904-900-1243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEROY R. POLITE
Title or Position: PRESIDENT
Credential:
Phone: 904-683-1769