Provider Demographics
NPI:1255795464
Name:HEADWATERS DENTAL MANAGEMENT
Entity type:Organization
Organization Name:HEADWATERS DENTAL MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:SEFCIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-547-4474
Mailing Address - Street 1:120 S STARDUST DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1631
Mailing Address - Country:US
Mailing Address - Phone:719-547-4474
Mailing Address - Fax:719-547-4710
Practice Address - Street 1:120 S STARDUST DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-1631
Practice Address - Country:US
Practice Address - Phone:719-547-4474
Practice Address - Fax:719-547-4710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002022981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80780580Medicaid