MEDICARE: MR. ELVIS LE DDS

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	39615	TX

General Provider Information

NPI Number	:	1568162162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ELVIS LE DDS

Provider Business Mailing Address
First Line	:	2501 W I 20
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3947
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2501 W I 20
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3947
Country	:	US
Telephone Number	:	817-200-7086
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2023
Last Update Date	:	06/10/2024

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