Healthcare Provider Details

I. General information

NPI: 1780652289
Provider Name (Legal Business Name): JOHN ALFRED KRETZSCHMAR D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 3 BOX 6352
APO AP
96266
KR

IV. Provider business mailing address

314 W 5TH AVE
CHEYENNE WY
82001-1248
US

V. Phone/Fax

Practice location:
  • Phone: 82168912886
  • Fax:
Mailing address:
  • Phone: 307-256-8397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7604
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: