Provider Demographics
NPI:1346858198
Name:FPDS LYO PLLC
Entity Type:Organization
Organization Name:FPDS LYO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSTIG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-335-0862
Mailing Address - Street 1:3575 LONE STAR CIR STE 310
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-8908
Mailing Address - Country:US
Mailing Address - Phone:817-350-6500
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty