Provider Demographics
NPI:1194328914
Name:MAGNOLIA DENTAL CARE, PLLC
Entity type:Organization
Organization Name:MAGNOLIA DENTAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LATTERELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-242-6618
Mailing Address - Street 1:401 N 2ND ST UNIT 410
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-1587
Mailing Address - Country:US
Mailing Address - Phone:763-242-6618
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S STE 270
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2119
Practice Address - Country:US
Practice Address - Phone:952-927-7744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty