MEDICARE: DR. FRED J DE LA COTERA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	021-001570	IL

General Provider Information

NPI Number	:	1437139185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FRED J DE LA COTERA DDS

Provider Business Mailing Address
First Line	:	7714 W NORTH AVE
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-4123
Country	:	US
Telephone Number	:	708-203-4095
Fax Number	:

Provider Business Practice Location Address
First Line	:	7714 W NORTH AVE
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-4123
Country	:	US
Telephone Number	:	708-456-7282
Fax Number	:	708-456-7296

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	01/11/2024

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