Provider Demographics
NPI:1043708050
Name:L & L PORT ORANGE, LLC
Entity type:Organization
Organization Name:L & L PORT ORANGE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LECOMPTE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:386-295-3815
Mailing Address - Street 1:3890 TURTLE CREEK DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127
Mailing Address - Country:US
Mailing Address - Phone:386-761-5440
Mailing Address - Fax:386-760-0474
Practice Address - Street 1:4904 S CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129
Practice Address - Country:US
Practice Address - Phone:386-788-9959
Practice Address - Fax:386-788-9850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN7283261QD0000X
FLDN12922261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental