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NPI Code Detail

MEDICARE: DR. ADAM JOHN RETALLICK D.D.S.

MEDICARE: DR. ADAM JOHN RETALLICK D.D.S.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223E0200XEndodontics60625KS

General Provider Information

NPI Number : 1760703425
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ADAM JOHN RETALLICK D.D.S.
Provider Business Mailing Address
First Line : 11113 W 122ND TER
Second Line :
City : OVERLAND PARK
State : KS
Zip : 66213-1951
Country : US
Telephone Number : 913-220-9367
Fax Number :
Provider Business Practice Location Address
First Line : 333 S SETH CHILD RD
Second Line :
City : MANHATTAN
State : KS
Zip : 66502-3003
Country : US
Telephone Number : 785-320-2277
Fax Number : 785-320-2182
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/17/2010
Last Update Date : 10/11/2011

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