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General NPI Number Information
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NPI Number | 1124364971
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Entity Type | Organization
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Legal Business Name | ECONOMY DENTISTRY DUPONT STATION
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Dates
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Enumeration Date | 12/26/2012
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Last Update Date | 12/26/2012
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Provider Practice Location Address
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Address Line | 3615 DUPONT AVE 200-400
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2790
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Country | US
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Telephone | 904-714-6939
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Fax | 904-751-9196
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Provider Business Mailing Address
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Address Line | 3615 DUPONT AVE 200-400
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2790
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Country | US
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Telephone | 904-714-6939
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Fax | 904-751-9196
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LEROY RONALD POLITE
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Credential | D.M.D
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Telephone | 904-714-6939
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN8243
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License Number State | FL
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