Provider Demographics
NPI:1497952816
Name:DELAFUENTE, CARLA JULISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:JULISSA
Last Name:DELAFUENTE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W ERIE ST STE 500
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-4032
Mailing Address - Country:US
Mailing Address - Phone:312-274-0308
Mailing Address - Fax:
Practice Address - Street 1:3057 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3548
Practice Address - Country:US
Practice Address - Phone:773-297-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190274311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice