Provider Demographics
NPI:1316013436
Name:LORD DENTAL, P.A.
Entity Type:Organization
Organization Name:LORD DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-904-9248
Mailing Address - Street 1:4509 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-3210
Mailing Address - Country:US
Mailing Address - Phone:817-546-1020
Mailing Address - Fax:
Practice Address - Street 1:4509 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3210
Practice Address - Country:US
Practice Address - Phone:817-546-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22028122300000X, 1223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177614801Medicaid
TXB2202801OtherCHIP