Provider Demographics
NPI:1760562235
Name:LUSTIG, JEREMY RUSSELL (DDS, MS, PA)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:RUSSELL
Last Name:LUSTIG
Suffix:
Gender:M
Credentials:DDS, MS, PA
Other - Prefix:DR
Other - First Name:JEREMY
Other - Middle Name:RUSSELL
Other - Last Name:LUSTIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS, PA
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
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics