Provider Demographics
NPI:1699668798
Name:DE LA FUENTE, EMANUEL EDWARDO (DMD)
Entity type:Individual
Prefix:
First Name:EMANUEL
Middle Name:EDWARDO
Last Name:DE LA FUENTE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3632 S AUSTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-4150
Mailing Address - Country:US
Mailing Address - Phone:773-969-9329
Mailing Address - Fax:
Practice Address - Street 1:7310 WALTON ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4614
Practice Address - Country:US
Practice Address - Phone:815-395-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program