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NPI Code Detail

MEDICARE: FPDS LYO PLLC

MEDICARE: FPDS LYO 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
11223X0400XOrthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number : 1346858198
Entity Type Code : Organization
Provider Name (Legal Business Name) : FPDS LYO PLLC
Provider Business Mailing Address
First Line : 3575 LONE STAR CIR STE 310
Second Line :
City : FORT WORTH
State : TX
Zip : 76177-8908
Country : US
Telephone Number : 817-350-6500
Fax Number :
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 :
Authorized Official
Title or Position : CEO
Name : JEREMY LUSTIG
Credential : DDS
Telephone Number : 214-335-0862
Provider Enumeration Date : 07/17/2020
Last Update Date : 07/17/2020

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Directions to “FPDS LYO PLLC ” Practice Location

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