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General NPI Number Information
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NPI Number | 1457405987
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Entity Type | Organization
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Legal Business Name | GREEN BAY TRAIL DENTISTRY
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 05/24/2011
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Provider Practice Location Address
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Address Line | 2632 GREEN BAY RD
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City | EVANSTON
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State | IL
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Zip | 60201
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Country | US
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Telephone | 847-869-4844
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Fax |
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Provider Business Mailing Address
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Address Line | 2632 GREEN BAY RD
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City | EVANSTON
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State | IL
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Zip | 60201
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Country | US
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Telephone | 847-869-4844
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Fax |
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Authorized Official
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Title or Position | OWNER PROVIDER
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Name | ERIC ESTES
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Credential | DDS
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Telephone | 847-869-4844
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019021406
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License Number State | IL
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