NPIMap

Individual provider Active NPI

Jeremy Russell Lustig, D.D.S., M.S., P.A.

  • Orthodontics and Dentofacial Orthopedics Dentistry
  • Fort Worth, TX
National Provider Identifier
1760562235
Registry record updated Feb 28, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X
License
20612 Issued in TX
Practice address
8450 Park Vista Blvd
Fort Worth, TX 76137-5731
Phone
(817) 514-1717
Fax
(817) 704-4771
NPI assigned
Oct 17, 2006
Last updated
Feb 28, 2024By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 28, 2024

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Orthodontics and Dentofacial Orthopedics Dentistry 1223X0400X 20612 TX Primary

Addresses

Primary practice location

8450 Park Vista Blvd
Fort Worth, TX 76137-5731

Mailing address

8450 Park Vista Blvd
Fort Worth, TX 76137-5731
Phone (817) 514-1717

Other practice location 1

705 W Bailey Boswell Rd Ste 100
Saginaw, TX 76179-1020
Phone (817) 514-1717

Other practice location 2

1025 Boyd Rd
Azle, TX 76020-2517
Phone (817) 514-1717

Other practice location 3

601 S Main St
Keller, TX 76248-7029
Phone (817) 514-1717

Other practice location 4

570 Fm 156 S Ste 200
Haslet, TX 76052-3626
Phone (817) 514-1717

Other names 1

  • Dr. Jeremy Russell Lustig Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled
Credentials
Master of Science, Physician Assistant

State licenses

LicenseStateTypeSpecialty
20612TXMDOrthodontics and Dentofacial Orthopedic Dentist

Practice roles

OrganizationSpecialtyStatusNew patients
Benham Orthodontics Orthodontics and Dentofacial Orthopedics Current Accepting new patients
FPDS Lyo PLLC Orthodontics and Dentofacial Orthopedics Current Accepting new patients
Benham Orthodontics Orthodontics and Dentofacial Orthopedics Current Accepting new patients
Lustig and Young Orthodontics Orthodontics and Dentofacial Orthopedics PastSince Mar 3, 2024 Accepting new patients
Lustig and Young Orthodontics Orthodontics and Dentofacial Orthopedics PastSince Mar 3, 2024 Accepting new patients

Locations

1025 Boyd Rd
Azle, TX 76020
Phone (817) 514-1717

8450 Park Vista Blvd
Fort Worth, TX 76137
Phone (817) 514-1717

570 FM 156 S
Ste 200
Haslet, TX 76052
Phone (817) 514-1717

705 W Bailey Boswell Rd
Ste 100
Saginaw, TX 76179
Phone (817) 514-1717

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

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

{
    "created_epoch": "1161043200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1709078400000",
    "number": "1760562235",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8450 PARK VISTA BLVD",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761375731",
            "telephone_number": "817-514-1717",
            "fax_number": "817-704-4771"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8450 PARK VISTA BLVD",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761375731",
            "telephone_number": "817-514-1717",
            "fax_number": "817-704-4771"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "705 W Bailey Boswell Rd Ste 100",
            "address_purpose": "LOCATION",
            "city": "Saginaw",
            "state": "TX",
            "postal_code": "761791020",
            "country_code": "US",
            "telephone_number": "817-514-1717",
            "fax_number": "817-704-4771",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1025 Boyd Rd",
            "address_purpose": "LOCATION",
            "city": "Azle",
            "state": "TX",
            "postal_code": "760202517",
            "country_code": "US",
            "telephone_number": "817-514-1717",
            "fax_number": "817-704-4771",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "601 S Main St",
            "address_purpose": "LOCATION",
            "city": "Keller",
            "state": "TX",
            "postal_code": "762487029",
            "country_code": "US",
            "telephone_number": "817-514-1717",
            "fax_number": "817-704-4771",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "570 Fm 156 S Ste 200",
            "address_purpose": "LOCATION",
            "city": "Haslet",
            "state": "TX",
            "postal_code": "760523626",
            "country_code": "US",
            "telephone_number": "817-514-1717",
            "fax_number": "817-704-4771",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "LUSTIG",
        "first_name": "JEREMY",
        "middle_name": "RUSSELL",
        "name_prefix": "Dr.",
        "credential": "D.D.S., M.S., P.A.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-10-17",
        "last_updated": "2024-02-28",
        "certification_date": "2024-02-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "TX",
            "license": "20612",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JEREMY",
            "last_name": "LUSTIG",
            "middle_name": "RUSSELL",
            "prefix": "DR.",
            "credential": "D.D.S., M.S., P.A.",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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, 2024; 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.