MEDICARE: LOFTUS FAMILY DENTAL - POST FALLS

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

General Provider Information

NPI Number	:	1912250366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOFTUS FAMILY DENTAL - POST FALLS

Provider Business Mailing Address
First Line	:	1850 E SELTICE WAY
Second Line	:
City	:	POST FALLS
State	:	ID
Zip	:	83854-7019
Country	:	US
Telephone Number	:	208-777-0292
Fax Number	:	208-777-0293

Provider Business Practice Location Address
First Line	:	1850 E SELTICE WAY
Second Line	:
City	:	POST FALLS
State	:	ID
Zip	:	83854-7019
Country	:	US
Telephone Number	:	208-777-0292
Fax Number	:	208-777-0293

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	RONEL MCCOMBS
Credential	:
Telephone Number	:	502-254-8500

Provider Enumeration Date	:	10/23/2012
Last Update Date	:	10/23/2012

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