=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528299153
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARL ERDMAN PENNAU DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2009
-----------------------------------------------------
Last Update Date | 07/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5745 ERINDALE DR SUITE 100
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80918-8926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-473-2650
-----------------------------------------------------
Fax | 719-473-2508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5745 ERINDALE DR SUITE 100
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80918-8926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-473-2650
-----------------------------------------------------
Fax | 719-473-2508
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DEN.00201814
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DE60213829
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------