Provider Demographics
NPI:1376840306
Name:CRYSTAL DENTAL OF FORT WORTH, P.C.
Entity Type:Organization
Organization Name:CRYSTAL DENTAL OF FORT WORTH, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-793-0013
Mailing Address - Street 1:2880 HIGHWAY 157 N
Mailing Address - Street 2:STE 102
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1114 E SEMINARY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-2830
Practice Address - Country:US
Practice Address - Phone:817-473-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21298305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158687708Medicaid
TX175019201Medicaid
TX204803503Medicaid