MEDICARE: LCD PRACTICE, 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1487511671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LCD PRACTICE, PLLC

Provider Business Mailing Address
First Line	:	8461 BOAT CLUB RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3607
Country	:	US
Telephone Number	:	817-236-8771
Fax Number	:	817-236-8771

Provider Business Practice Location Address
First Line	:	8461 BOAT CLUB RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3607
Country	:	US
Telephone Number	:	817-236-8771
Fax Number	:	817-236-8771

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KELLEY EASTER
Credential	:
Telephone Number	:	817-236-8771

Provider Enumeration Date	:	01/08/2026
Last Update Date	:	01/09/2026

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