MEDICARE: JAMES C.LOOTS JR. DDS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D10409	MN

General Provider Information

NPI Number	:	1992134324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAMES C.LOOTS JR. DDS PA

Provider Business Mailing Address
First Line	:	535 40TH AVE NE
Second Line	:
City	:	COLUMBIA HTS
State	:	MN
Zip	:	55421-3836
Country	:	US
Telephone Number	:	763-781-3321
Fax Number	:	763-781-5744

Provider Business Practice Location Address
First Line	:	535 40TH AVE NE
Second Line	:
City	:	COLUMBIA HTS
State	:	MN
Zip	:	55421-3836
Country	:	US
Telephone Number	:	763-781-3321
Fax Number	:	763-781-5744

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAMES CLARENCE LOOTS JR.
Credential	:	DDS
Telephone Number	:	763-781-3321

Provider Enumeration Date	:	11/06/2013
Last Update Date	:	11/06/2013

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