Provider Demographics
NPI:1740661388
Name:LOFTUS FAMILY DENTAL
Entity type:Organization
Organization Name:LOFTUS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GUADALUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-340-1054
Mailing Address - Street 1:2615 N FRUITLAND LN
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7914
Mailing Address - Country:US
Mailing Address - Phone:435-340-1054
Mailing Address - Fax:
Practice Address - Street 1:2615 N FRUITLAND LN
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7914
Practice Address - Country:US
Practice Address - Phone:435-340-1054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4664305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service