Provider Demographics
NPI:1861666786
Name:JEFFREY D LOVELESS DDS PA
Entity Type:Organization
Organization Name:JEFFREY D LOVELESS DDS PA
Other - Org Name:PRAIRIE RIDGE ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:LOVELESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:507-451-5993
Mailing Address - Street 1:475 26TH STREET NE
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060
Mailing Address - Country:US
Mailing Address - Phone:507-451-5993
Mailing Address - Fax:507-451-5856
Practice Address - Street 1:475 26TH ST NE
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060
Practice Address - Country:US
Practice Address - Phone:507-451-5993
Practice Address - Fax:507-451-5856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNMHCP715324400OtherMN DEPT HUMAN SERVICES
MN9179850OtherDORAL DENTAL