Provider Demographics
NPI:1013044890
Name:LOFTIS, KENLEY JACKSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENLEY
Middle Name:JACKSON
Last Name:LOFTIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 SUNSET BLVD.
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-6722
Mailing Address - Country:US
Mailing Address - Phone:803-794-8741
Mailing Address - Fax:803-794-2149
Practice Address - Street 1:1429 SUNSET BLVD.
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6722
Practice Address - Country:US
Practice Address - Phone:803-794-8741
Practice Address - Fax:803-794-2149
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice