Provider Demographics
NPI:1710286661
Name:LOFTIN, JUSTIN BRAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:BRAD
Last Name:LOFTIN
Suffix:
Gender:M
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:PO BOX 889
Mailing Address - Street 2:
Mailing Address - City:MENARD
Mailing Address - State:TX
Mailing Address - Zip Code:76859-0889
Mailing Address - Country:US
Mailing Address - Phone:325-396-2417
Mailing Address - Fax:
Practice Address - Street 1:108 W SAN SABA AVE
Practice Address - Street 2:
Practice Address - City:MENARD
Practice Address - State:TX
Practice Address - Zip Code:76859
Practice Address - Country:US
Practice Address - Phone:325-396-2417
Practice Address - Fax:325-396-2421
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00263061223G0001X
VA04014129971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice