MEDICARE: LORD DENTAL, P.A.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	22028	TX
2	122300000X	Dentist	22028	TX
3	1223G0001X	General Practice Dentistry	22028	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	B2202801	OTHER	TX	CHIP

General Provider Information

NPI Number	:	1316013436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LORD DENTAL, P.A.

Provider Business Mailing Address
First Line	:	4509 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3210
Country	:	US
Telephone Number	:	817-546-1020
Fax Number	:

Provider Business Practice Location Address
First Line	:	4509 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3210
Country	:	US
Telephone Number	:	817-546-1020
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LEYLA LORD
Credential	:	D.M.D.
Telephone Number	:	972-904-9248

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	05/11/2016

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Directions to “LORD DENTAL, P.A. ” Practice Location

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