Provider Demographics
NPI:1457405987
Name:GREEN BAY TRAIL DENTISTRY
Entity Type:Organization
Organization Name:GREEN BAY TRAIL DENTISTRY
Other - Org Name:ERIC ESTES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-869-4844
Mailing Address - Street 1:2632 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-869-4844
Mailing Address - Fax:
Practice Address - Street 1:2632 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-869-4844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty