Provider Demographics
NPI:1497982318
Name:LATTERELL, SARAH ROSE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:ROSE
Last Name:LATTERELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ROSE
Other - Last Name:DOHENY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10945 ULYSSES STREET NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434
Mailing Address - Country:US
Mailing Address - Phone:763-784-1993
Mailing Address - Fax:763-784-1575
Practice Address - Street 1:10945 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4185
Practice Address - Country:US
Practice Address - Phone:763-784-1993
Practice Address - Fax:763-784-1575
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12679122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist