MEDICARE: DR. KENLEY JACKSON LOFTIS D.M.D.

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	1223G0001X	General Practice Dentistry	3331	SC

General Provider Information

NPI Number	:	1013044890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENLEY JACKSON LOFTIS D.M.D.

Provider Business Mailing Address
First Line	:	1429 SUNSET BLVD.
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-6722
Country	:	US
Telephone Number	:	803-794-8741
Fax Number	:	803-794-2149

Provider Business Practice Location Address
First Line	:	1429 SUNSET BLVD.
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-6722
Country	:	US
Telephone Number	:	803-794-8741
Fax Number	:	803-794-2149

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	09/29/2010

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