Headwaters Dental Management

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

00202298 Issued in CO

Legal business name

HEADWATERS DENTAL MANAGEMENT

Doing business as

Pueblo West Dental Care

Practice address

120 S Stardust Dr
Pueblo West, CO 81007-1631

Phone

(719) 547-4474

Fax

(719) 547-4710

NPI assigned

Apr 13, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Brady Sefcik

Title

DDS/Owner

Phone

(719) 547-4474

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Pueblo West Dental Care Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1460505600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1460505600000",
    "number": "1255795464",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 S STARDUST DR",
            "city": "PUEBLO WEST",
            "state": "CO",
            "postal_code": "810071631",
            "telephone_number": "719-547-4474",
            "fax_number": "719-547-4710"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 S STARDUST DR",
            "city": "PUEBLO WEST",
            "state": "CO",
            "postal_code": "810071631",
            "telephone_number": "719-547-4474",
            "fax_number": "719-547-4710"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HEADWATERS DENTAL MANAGEMENT",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-04-13",
        "last_updated": "2016-04-13",
        "status": "A",
        "authorized_official_last_name": "SEFCIK",
        "authorized_official_first_name": "BRADY",
        "authorized_official_title_or_position": "DDS/OWNER",
        "authorized_official_telephone_number": "719-547-4474",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "CO",
            "license": "00202298",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "80780580",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pueblo West Dental Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Clive Russell Hallam, LMFT
• Talal I Hamki, BS PHARMACY
• Hanson Clinic PC
• Hanson Clinic PC
• Joan L. Hatcher
• Preston Scott Heinen, FNP-C
• Theresa Herrera, NREMT-B IV CERTIFIED
• Melissa Lynn Hollis, COTA
• Lauren Hornbeck, MA, LPC, NCC
• Lisa Horner

• General Practice Dentistry in Pueblo West, CO
• Providers in Pueblo West, CO by specialty
• General Practice Dentistry in Colorado

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 13, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.