=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619871829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMA TELLO DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2026
-----------------------------------------------------
Last Update Date | 10/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 BOULDER HILL PASS
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60538-1951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-896-5013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4429 BELMONT RD
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-983-1688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.037124
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------