Provider Demographics
NPI:1720580061
Name:DERTINGER, RYAN EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:EDWARD
Last Name:DERTINGER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 CRESTWOOD TER
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-3719
Mailing Address - Country:US
Mailing Address - Phone:847-630-7567
Mailing Address - Fax:847-630-7567
Practice Address - Street 1:700 BRANCH ST STE 10
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-9298
Practice Address - Country:US
Practice Address - Phone:816-232-5113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA090090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor