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General NPI Number Information
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NPI Number | 1699668798
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Entity Type | Individual
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Provider Name | EMANUEL EDWARDO DE LA FUENTE DMD
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Gender | Male
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Dates
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Enumeration Date | 05/29/2025
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Last Update Date | 07/15/2025
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Provider Practice Location Address
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Address Line | 7310 WALTON ST
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City | ROCKFORD
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State | IL
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Zip | 61108-4614
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Country | US
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Telephone | 815-395-5555
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Fax |
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Provider Business Mailing Address
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Address Line | 3632 S AUSTIN BLVD
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City | CICERO
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State | IL
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Zip | 60804-4150
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Country | US
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Telephone | 773-969-9329
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.036286
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License Number State | IL
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