Provider Demographics
NPI:1598728123
Name:LARA, SANDRA (DDS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:520 MAIN STREET
Mailing Address - City:HAWLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56549-0849
Mailing Address - Country:US
Mailing Address - Phone:218-483-1339
Mailing Address - Fax:
Practice Address - Street 1:520 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:MN
Practice Address - Zip Code:56549-4726
Practice Address - Country:US
Practice Address - Phone:218-483-1339
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND118321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice