Provider Demographics
NPI:1306227731
Name:LUSTIG AND YOUNG ORTHODONTICS
Entity Type:Organization
Organization Name:LUSTIG AND YOUNG ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSTIG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, PA
Authorized Official - Phone:817-350-6500
Mailing Address - Street 1:8450 PARK VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-5731
Mailing Address - Country:US
Mailing Address - Phone:817-514-1717
Mailing Address - Fax:817-704-4771
Practice Address - Street 1:8450 PARK VISTA BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-5731
Practice Address - Country:US
Practice Address - Phone:817-514-1717
Practice Address - Fax:817-704-4771
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FPDS LYO PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-11
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty