NPIMap

Organization Active NPI

Crystal Dental of Fort Worth, P.C.

  • Preferred Provider Organization
  • Fort Worth, TX
National Provider Identifier
1376840306
Registry record updated Feb 28, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Preferred Provider OrganizationTaxonomy code 305R00000X
License
21298 Issued in TX
Legal business name
CRYSTAL DENTAL OF FORT WORTH, P.C.
Practice address
1114 E Seminary Dr
Fort Worth, TX 76115-2830
Phone
(817) 473-6200
NPI assigned
Feb 28, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 28, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Brian T Le, DDSNPI 1730177619
Title
Owner/Dentist
Phone
(817) 793-0013

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Preferred Provider Organization 305R00000X 21298 TX Primary

Addresses

Primary practice location

1114 E Seminary Dr
Fort Worth, TX 76115-2830

Mailing address

2880 Highway 157 N
Ste 102
Mansfield, TX 76063-8849

Other identifiers 3

IdentifierTypeStateIssuer
158687708MedicaidTX
175019201MedicaidTX
204803503MedicaidTX

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1298851200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1298851200000",
    "number": "1376840306",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2880 HIGHWAY 157 N",
            "address_2": "STE 102",
            "city": "MANSFIELD",
            "state": "TX",
            "postal_code": "760638849"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1114 E SEMINARY DR",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761152830",
            "telephone_number": "817-473-6200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRYSTAL DENTAL OF FORT WORTH, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-28",
        "last_updated": "2011-02-28",
        "status": "A",
        "authorized_official_last_name": "LE",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "OWNER/DENTIST",
        "authorized_official_telephone_number": "817-793-0013",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": "TX",
            "license": "21298",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "158687708",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "175019201",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "204803503",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Worth, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.