Provider Demographics
NPI:1962511030
Name:WITTENBERGER, DARREN ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DARREN
Middle Name:ALAN
Last Name:WITTENBERGER
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 1:201 W BROADWAY STE 3I
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-3842
Mailing Address - Country:US
Mailing Address - Phone:573-449-7633
Mailing Address - Fax:
Practice Address - Street 1:201 W BROADWAY STE 3I
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3842
Practice Address - Country:US
Practice Address - Phone:573-449-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010149551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV10977Medicare UPIN