1790246411 NPI number — ECONOMY DENTISTRY FOR CHILDREN - DUPONT STATION, LLC

Table of content: (NPI 1790246411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790246411 NPI number — ECONOMY DENTISTRY FOR CHILDREN - DUPONT STATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ECONOMY DENTISTRY FOR CHILDREN - DUPONT STATION, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790246411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3615 DUPONT AVE STE 200-400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32217-2790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-683-1769
Provider Business Mailing Address Fax Number:
904-900-1243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1319 E OSCEOLA PKWY STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34744-1606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-683-1769
Provider Business Practice Location Address Fax Number:
904-900-1243
Provider Enumeration Date:
03/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
POLITE
Authorized Official First Name:
LEROY
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
904-683-1769

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008817801 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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