Healthcare Provider Details

I. General information

NPI: 1619329448
Provider Name (Legal Business Name): NATHAN HEYWOOD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 MAIN ST
WALSENBURG CO
81089-2136
US

IV. Provider business mailing address

624 MAIN ST
WALSENBURG CO
81089-2136
US

V. Phone/Fax

Practice location:
  • Phone: 719-695-1004
  • Fax:
Mailing address:
  • Phone: 719-695-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number00203138
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: