Provider Demographics
NPI:1528211489
Name:MATA, FELICIA S (DMD)
Entity Type:Individual
Prefix:DR
First Name:FELICIA
Middle Name:S
Last Name:MATA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 822
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-263-6793
Mailing Address - Fax:312-263-0906
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 822
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-263-6793
Practice Address - Fax:312-263-0906
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190243021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1417034851OtherDENTAL