Provider Demographics
NPI:1821543513
Name:BLUE WATER DENTAL OF ST. JOHNS
Entity type:Organization
Organization Name:BLUE WATER DENTAL OF ST. JOHNS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-755-1966
Mailing Address - Street 1:334 WILLOW WINDS PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7268
Mailing Address - Country:US
Mailing Address - Phone:904-755-1966
Mailing Address - Fax:
Practice Address - Street 1:460 TOWN PLAZA AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5139
Practice Address - Country:US
Practice Address - Phone:904-755-1966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20719305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1831508084OtherINDIVIDUAL NPI