MEDICARE: CRYSTAL DENTAL, 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
1	1223G0001X	General Practice Dentistry	21298	TX

General Provider Information

NPI Number	:	1780693960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL DENTAL, P.A.

Provider Business Mailing Address
First Line	:	1114 E. SEMINARY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115
Country	:	US
Telephone Number	:	817-921-0883
Fax Number	:	888-600-6547

Provider Business Practice Location 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

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRIAN T. LE
Credential	:	D.D.S.
Telephone Number	:	817-473-6200

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	03/06/2018

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