Provider Demographics
NPI:1730177619
Name:LE, BRIAN T (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:T
Last Name:LE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 E SEMINARY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-2830
Mailing Address - Country:US
Mailing Address - Phone:817-921-0883
Mailing Address - Fax:888-600-6547
Practice Address - Street 1:1114 E SEMINARY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-2830
Practice Address - Country:US
Practice Address - Phone:817-921-0883
Practice Address - Fax:888-600-6547
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158687712Medicaid
TX158687715Medicaid
TX158687716Medicaid
TX158687713Medicaid