MEDICARE: DR. EDD B WITTENBERG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6775	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	777871	OTHER	CO	UNITED CONCORDIA ID #

General Provider Information

NPI Number	:	1114004116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDD B WITTENBERG DDS

Provider Business Mailing Address
First Line	:	7222 COMMERCE CENTER DR
Second Line	:	SUITE 247
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-2630
Country	:	US
Telephone Number	:	719-593-0403
Fax Number	:	719-593-0767

Provider Business Practice Location Address
First Line	:	7222 COMMERCE CENTER DR
Second Line	:	SUITE 247
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-2630
Country	:	US
Telephone Number	:	719-593-0403
Fax Number	:	719-593-0767

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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