Provider Demographics
NPI:1033295464
Name:FAYE E LICATA DMD FAGD PC
Entity Type:Organization
Organization Name:FAYE E LICATA DMD FAGD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:E
Authorized Official - Last Name:LICATA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-532-2101
Mailing Address - Street 1:111 HILLTOWN VILLAGE CENTER
Mailing Address - Street 2:SUITE #200
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017
Mailing Address - Country:US
Mailing Address - Phone:636-532-2101
Mailing Address - Fax:636-532-2209
Practice Address - Street 1:111 HILLTOWN VILLAGE CENTER
Practice Address - Street 2:SUITE #200
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017
Practice Address - Country:US
Practice Address - Phone:636-532-2101
Practice Address - Fax:636-532-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015059122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty