Provider Demographics
NPI:1497148860
Name:LOFTUS FAMILY DENTAL - SANDPOINT PLLC
Entity Type:Organization
Organization Name:LOFTUS FAMILY DENTAL - SANDPOINT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LOFTUS
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-765-3301
Mailing Address - Street 1:2615 N FRUITLAND LANE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815
Mailing Address - Country:US
Mailing Address - Phone:208-765-3301
Mailing Address - Fax:208-765-9282
Practice Address - Street 1:1310 PONDEROSA DRIVE, SUITE A
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864
Practice Address - Country:US
Practice Address - Phone:208-263-7641
Practice Address - Fax:208-265-4333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGE J LOFTUS III, DDS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-10
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID28512Medicaid