=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619591401
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TEAL NICHOLE ESTES DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2020
-----------------------------------------------------
Last Update Date | 11/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1315 W WESTRIDGE PKWY
-----------------------------------------------------
City | GREENSBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47240-3251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-663-7515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 997 TIMBER CREEK LN
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46142-5068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-592-1113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12013376A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------