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NPI Code Detail

MEDICARE: DR. JEREMY RUSSELL LUSTIG D.D.S., M.S., P.A.

MEDICARE: DR. JEREMY RUSSELL LUSTIG D.D.S., M.S., P.A.
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 Dentistry20612TX

General Provider Information

NPI Number : 1760562235
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JEREMY RUSSELL LUSTIG D.D.S., M.S., P.A.
Provider Business Mailing 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 : 817-704-4771
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 : 817-704-4771
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/17/2006
Last Update Date : 02/28/2024

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Directions to “ DR. JEREMY RUSSELL LUSTIG D.D.S., M.S., P.A.” Practice Location

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