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General NPI Number Information
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NPI Number | 1740661388
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Entity Type | Organization
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Legal Business Name | LOFTUS FAMILY DENTAL
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Dates
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Enumeration Date | 06/09/2015
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Last Update Date | 06/09/2015
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Provider Practice Location Address
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Address Line | 2615 N FRUITLAND LN
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City | COEUR D ALENE
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State | ID
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Zip | 83815-7914
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Country | US
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Telephone | 435-340-1054
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Fax |
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Provider Business Mailing Address
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Address Line | 2615 N FRUITLAND LN
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City | COEUR D ALENE
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State | ID
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Zip | 83815-7914
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Country | US
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Telephone | 435-340-1054
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. GUADALUPE GUTIERREZ
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Credential | DMD
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Telephone | 435-340-1054
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | D-4664
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License Number State | ID
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