Provider Demographics
NPI:1417034851
Name:FELICIA S MATA DMD LTD
Entity Type:Organization
Organization Name:FELICIA S MATA DMD LTD
Other - Org Name:WINDSOR I DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-244-7340
Mailing Address - Street 1:501 N RIVERSIDE DR
Mailing Address - Street 2:STE 119 WINDSOR I DENTAL CARE
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031
Mailing Address - Country:US
Mailing Address - Phone:847-244-7340
Mailing Address - Fax:847-244-7390
Practice Address - Street 1:501 N RIVERSIDE DR
Practice Address - Street 2:STE 119 WINDSOR I DENTAL CARE
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:847-244-7340
Practice Address - Fax:847-244-7390
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOOP DENTAL CARE LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024302122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty