Healthcare Provider Details

I. General information

NPI: 1841637196
Provider Name (Legal Business Name): DIANA VU DAO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 E BERRY ST
FORT WORTH TX
76105-4755
US

IV. Provider business mailing address

2906 E BERRY ST
FORT WORTH TX
76105-4755
US

V. Phone/Fax

Practice location:
  • Phone: 512-619-1191
  • Fax:
Mailing address:
  • Phone: 512-619-1191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number28934
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number28934
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: