Healthcare Provider Details

I. General information

NPI: 1508375965
Provider Name (Legal Business Name): DIOMS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9676 BARTLETT CIR STE 950
FORT WORTH TX
76108-4469
US

IV. Provider business mailing address

9676 BARTLETT CIR STE 950
FORT WORTH TX
76108-4469
US

V. Phone/Fax

Practice location:
  • Phone: 817-945-2971
  • Fax: 817-841-1074
Mailing address:
  • Phone: 817-945-2971
  • Fax: 817-841-1074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number25803
License Number StateTX

VIII. Authorized Official

Name: DR. MAU K PHAM
Title or Position: OWNER
Credential: DDS, MD
Phone: 817-945-2971