=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598179939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE SARAH DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2014
-----------------------------------------------------
Last Update Date | 06/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7500 STATE HIGHWAY 55 SUITE 200
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-575-8038
-----------------------------------------------------
Fax | 763-575-8039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7500 STATE HIGHWAY 55 SUITE 200
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-575-8038
-----------------------------------------------------
Fax | 763-575-8039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SARAH JOANNE MAGNUSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 612-718-7361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D12538
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------