Provider Demographics
NPI:1598179939
Name:LAKE SARAH DENTAL PLLC
Entity Type:Organization
Organization Name:LAKE SARAH DENTAL PLLC
Other - Org Name:LAKE SARAH DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-718-7361
Mailing Address - Street 1:7500 STATE HIGHWAY 55
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55373
Mailing Address - Country:US
Mailing Address - Phone:763-575-8038
Mailing Address - Fax:763-575-8039
Practice Address - Street 1:7500 STATE HIGHWAY 55
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENFIELD
Practice Address - State:MN
Practice Address - Zip Code:55373
Practice Address - Country:US
Practice Address - Phone:763-575-8038
Practice Address - Fax:763-575-8039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND125381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty