MEDICARE: JORDAN RANCH MODERN DENTISTRY, PC

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

General Provider Information

NPI Number	:	1922975390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JORDAN RANCH MODERN DENTISTRY, PC

Provider Business Mailing Address
First Line	:	PO BOX 660041
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75266-0041
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	303-952-0892

Provider Business Practice Location Address
First Line	:	2515 TEXAS HERITAGE PKWY, SUITE 510
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494
Country	:	US
Telephone Number	:	281-256-1790
Fax Number	:	281-644-0553

Authorized Official
Title or Position	:	OWNER
Name	:	ERIK TRUNG LE
Credential	:	DDS
Telephone Number	:	281-256-1790

Provider Enumeration Date	:	10/21/2025
Last Update Date	:	10/21/2025

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