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NPI Code Detail

MEDICARE: LUSTIG AND YOUNG ORTHODONTICS

MEDICARE: LUSTIG AND YOUNG ORTHODONTICS
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
1261QD0000XDental Clinic/Center
21223X0400XOrthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number : 1306227731
Entity Type Code : Organization
Provider Name (Legal Business Name) : LUSTIG AND YOUNG ORTHODONTICS
Provider Business Mailing Address
First Line : 8450 PARK VISTA BLVD
Second Line :
City : FORT WORTH
State : TX
Zip : 76137-5731
Country : US
Telephone Number : 817-514-1717
Fax Number : 817-704-4771
Provider Business Practice Location Address
First Line : 8450 PARK VISTA BLVD
Second Line :
City : FORT WORTH
State : TX
Zip : 76137-5731
Country : US
Telephone Number : 817-514-1717
Fax Number : 817-704-4771
Authorized Official
Title or Position : OWNER
Name : JEREMY LUSTIG
Credential : DDS, MS, PA
Telephone Number : 817-350-6500
Provider Enumeration Date : 06/11/2015
Last Update Date : 03/01/2024

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Directions to “LUSTIG AND YOUNG ORTHODONTICS ” Practice Location

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