Provider Demographics
NPI:1760596308
Name:WITTENBERG, RICHARD BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BRIAN
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 1:3880 ZIRCON LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-2837
Mailing Address - Country:US
Mailing Address - Phone:763-478-8554
Mailing Address - Fax:
Practice Address - Street 1:13055 RIVERDALE DR NW
Practice Address - Street 2:SUITE 400
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-8403
Practice Address - Country:US
Practice Address - Phone:612-243-9357
Practice Address - Fax:763-323-7487
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN87871223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics