Healthcare Provider Details

I. General information

NPI: 1760703425
Provider Name (Legal Business Name): ADAM JOHN RETALLICK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S SETH CHILD RD
MANHATTAN KS
66502-3003
US

IV. Provider business mailing address

11113 W 122ND TER
OVERLAND PARK KS
66213-1951
US

V. Phone/Fax

Practice location:
  • Phone: 785-320-2277
  • Fax: 785-320-2182
Mailing address:
  • Phone: 913-220-9367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number60625
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: