Provider Demographics
NPI:1578624409
Name:TJ LOFTUS DENTAL P.C.
Entity Type:Organization
Organization Name:TJ LOFTUS DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOFTUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-347-8880
Mailing Address - Street 1:866 LAZELLE ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-1611
Mailing Address - Country:US
Mailing Address - Phone:605-347-8880
Mailing Address - Fax:605-347-2011
Practice Address - Street 1:866 LAZELLE ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-1611
Practice Address - Country:US
Practice Address - Phone:605-347-8880
Practice Address - Fax:605-347-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM8521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7802040Medicaid