Organization
CRYSTAL DENTAL OF FORT WORTH, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRIAN T LE DDS (OWNER/DENTIST)
(817) 793-0013
Entity
Organization
Contact information
Practice address
1114 E SEMINARY DR, FORT WORTH, TX 76115-2830
(817) 473-6200
Mailing address
2880 HIGHWAY 157 N, STE 102, MANSFIELD, TX 76063-8849
Taxonomy
Speciality
Code
Description
License number
State
305R00000X
Preferred Provider Organization
Primary
21298
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
158687708
—
TX
05
—
175019201
—
TX
05
—
204803503
—
TX
Enumeration date
02/28/2011
Last updated
02/28/2011
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