Provider Demographics
NPI:1558374561
Name:HEADWATERS DENTAL
Entity Type:Organization
Organization Name:HEADWATERS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WINSLOW FEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-333-6515
Mailing Address - Street 1:2229 23RD ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5503
Mailing Address - Country:US
Mailing Address - Phone:218-333-6515
Mailing Address - Fax:218-333-6519
Practice Address - Street 1:2229 23RD ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5503
Practice Address - Country:US
Practice Address - Phone:218-333-6515
Practice Address - Fax:218-333-6519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN96501800Medicaid
MN084517500Medicaid