Provider Demographics
NPI:1346299690
Name:KODITEK, EDWARD ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ANTHONY
Last Name:KODITEK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:EDWARD
Other - Middle Name:ANTHONY
Other - Last Name:KODITEK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:230 CHATHAM DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4868
Mailing Address - Country:US
Mailing Address - Phone:719-576-8985
Mailing Address - Fax:
Practice Address - Street 1:230 CHATHAM DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4868
Practice Address - Country:US
Practice Address - Phone:719-576-8985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7696122300000X
CA245631223G0001X
CODEN.00007696122300000X
CODEN-76961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice