Healthcare Provider Details

I. General information

NPI: 1609633155
Provider Name (Legal Business Name): LUSTIG AND YOUNG ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 FM 156 S STE 200
HASLET TX
76052-3626
US

IV. Provider business mailing address

8450 PARK VISTA BLVD
FORT WORTH TX
76137-5731
US

V. Phone/Fax

Practice location:
  • Phone: 817-514-1717
  • Fax: 817-704-4771
Mailing address:
  • Phone: 817-514-1717
  • Fax: 817-704-4771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY LUSTIG
Title or Position: OWNER
Credential:
Phone: 817-350-6500