Provider Demographics
NPI:1811268121
Name:GEORGE J LOFTUS III, DDS, LLC
Entity type:Organization
Organization Name:GEORGE J LOFTUS III, DDS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOFTUS
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-765-3301
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:208-765-3301
Mailing Address - Fax:208-765-9282
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:208-765-3301
Practice Address - Fax:208-765-9282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD30191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty