Provider Demographics
NPI:1508037128
Name:CRYSTAL DENTAL OF BURLESON
Entity Type:Organization
Organization Name:CRYSTAL DENTAL OF BURLESON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
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:817-426-3331
Mailing Address - Street 1:2880 HIGHWAY 157 N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8849
Mailing Address - Country:US
Mailing Address - Phone:817-473-6200
Mailing Address - Fax:817-473-6207
Practice Address - Street 1:664 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5851
Practice Address - Country:US
Practice Address - Phone:817-426-3331
Practice Address - Fax:817-426-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-23
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212981223G0001X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1730177619Medicaid