Provider Demographics
NPI:1114004116
Name:WITTENBERG, EDD B (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDD
Middle Name:B
Last Name:WITTENBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7222 COMMERCE CENTER DR
Mailing Address - Street 2:SUITE 247
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2630
Mailing Address - Country:US
Mailing Address - Phone:719-593-0403
Mailing Address - Fax:719-593-0767
Practice Address - Street 1:7222 COMMERCE CENTER DR
Practice Address - Street 2:SUITE 247
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2630
Practice Address - Country:US
Practice Address - Phone:719-593-0403
Practice Address - Fax:719-593-0767
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO67751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO777871OtherUNITED CONCORDIA ID #