Provider Demographics
NPI:1710078803
Name:LOFTIS, LISA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:LYNN
Last Name:LOFTIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR29051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
58744OtherBLUE CROSS BLUE SHIELD
03090017900OtherQUAL CHOICE
831360OtherUNITED CONCORDIA