Provider Demographics
NPI:1437139185
Name:DE LA COTERA, FRED J (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:J
Last Name:DE LA COTERA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7714 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-4123
Mailing Address - Country:US
Mailing Address - Phone:708-203-4095
Mailing Address - Fax:
Practice Address - Street 1:7714 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-4123
Practice Address - Country:US
Practice Address - Phone:708-456-7282
Practice Address - Fax:708-456-7296
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0015701223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU24165Medicare UPIN