Provider Demographics
NPI:1558452409
Name:LISA L. LOFTIS, D.D.S., P.A.
Entity Type:Organization
Organization Name:LISA L. LOFTIS, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LOFTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-332-4979
Mailing Address - Street 1:306 S ASH ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-3918
Mailing Address - Country:US
Mailing Address - Phone:501-332-4979
Mailing Address - Fax:501-337-7097
Practice Address - Street 1:306 S ASH ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-3918
Practice Address - Country:US
Practice Address - Phone:501-332-4979
Practice Address - Fax:501-337-7097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2905305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
03090017900OtherQUAL CHOICE
58744OtherBLUECROSS BLUESHIELD FED
831360OtherUNITED CONCORDIA