Healthcare Provider Details

I. General information

NPI: 1437840659
Provider Name (Legal Business Name): TELIANE SUELLA BAKALA-MPANDZOU DMD, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 CAPITAL ST STE 500
ELGIN IL
60124-8078
US

IV. Provider business mailing address

2354 W POLK ST UNIT 403
CHICAGO IL
60612-5801
US

V. Phone/Fax

Practice location:
  • Phone: 773-920-8841
  • Fax:
Mailing address:
  • Phone: 773-920-8841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number021003518
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: