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NPI Code Detail

MEDICARE: DR. CARLA JULISSA DELAFUENTE DDS

MEDICARE: DR. CARLA JULISSA DELAFUENTE 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
11223G0001XGeneral Practice Dentistry19027431IL

General Provider Information

NPI Number : 1497952816
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CARLA JULISSA DELAFUENTE DDS
Provider Business Mailing Address
First Line : 430 W ERIE ST STE 500
Second Line :
City : CHICAGO
State : IL
Zip : 60610-4032
Country : US
Telephone Number : 312-274-0308
Fax Number :
Provider Business Practice Location Address
First Line : 3057 W CERMAK RD
Second Line :
City : CHICAGO
State : IL
Zip : 60623-3548
Country : US
Telephone Number : 773-297-0200
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/29/2007
Last Update Date : 07/08/2007

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