MEDICARE: CRYSTAL DENTAL OF FORT WORTH, P.C.

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	305R00000X	Preferred Provider Organization	21298	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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376840306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL DENTAL OF FORT WORTH, P.C.

Provider Business Mailing Address
First Line	:	2880 HIGHWAY 157 N
Second Line	:	STE 102
City	:	MANSFIELD
State	:	TX
Zip	:	76063-8849
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1114 E SEMINARY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-2830
Country	:	US
Telephone Number	:	817-473-6200
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. BRIAN T LE
Credential	:	DDS
Telephone Number	:	817-793-0013

Provider Enumeration Date	:	02/28/2011
Last Update Date	:	02/28/2011

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