MEDICARE: CREST FAMILY DENTAL FORT WORTH PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	22755	TX

General Provider Information

NPI Number	:	1104273341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREST FAMILY DENTAL FORT WORTH PLLC

Provider Business Mailing Address
First Line	:	2823 KENDALE DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75220-4736
Country	:	US
Telephone Number	:	214-350-8800
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 E SEMINARY DR
Second Line	:	SUITE 100
City	:	FORT WORTH
State	:	TX
Zip	:	76115-2607
Country	:	US
Telephone Number	:	817-484-6468
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	LAN CHI LE
Credential	:	DDS
Telephone Number	:	214-350-8800

Provider Enumeration Date	:	05/18/2016
Last Update Date	:	05/18/2016

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