Provider Demographics
NPI:1326414103
Name:RETRUM, JOSEPH KURT (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:KURT
Last Name:RETRUM
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 DICKENS AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-2465
Mailing Address - Country:US
Mailing Address - Phone:317-418-3870
Mailing Address - Fax:
Practice Address - Street 1:4010 1ST DIVISION RD
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442
Practice Address - Country:US
Practice Address - Phone:785-239-4173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012373A122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist