Healthcare Provider Details

I. General information

NPI: 1205856598
Provider Name (Legal Business Name): DIEU QUANG PHAM M.D., D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 12/03/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17150 EUCLID ST STE 319
FOUNTAIN VALLEY CA
92708-4092
US

IV. Provider business mailing address

17150 EUCLID ST STE 319
FOUNTAIN VALLEY CA
92708-4092
US

V. Phone/Fax

Practice location:
  • Phone: 714-444-2274
  • Fax: 714-444-2034
Mailing address:
  • Phone: 714-444-2274
  • Fax: 714-444-2034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA85351
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: