MEDICARE: CRYSTAL DENTAL OF BURLESON

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	1223G0001X	General Practice Dentistry	21298	TX
2	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

General Provider Information

NPI Number	:	1508037128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL DENTAL OF BURLESON

Provider Business Mailing Address
First Line	:	2880 HIGHWAY 157 N
Second Line	:	SUITE 102
City	:	MANSFIELD
State	:	TX
Zip	:	76063-8849
Country	:	US
Telephone Number	:	817-473-6200
Fax Number	:	817-473-6207

Provider Business Practice Location Address
First Line	:	664 SW WILSHIRE BLVD
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-5851
Country	:	US
Telephone Number	:	817-426-3331
Fax Number	:	817-426-3337

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. BRIAN T. LE
Credential	:	D.D.S.
Telephone Number	:	817-426-3331

Provider Enumeration Date	:	03/23/2008
Last Update Date	:	07/07/2009

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Directions to “CRYSTAL DENTAL OF BURLESON ” Practice Location

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