Provider Demographics
NPI:1831508084
Name:SORENSEN, DAVID WALLACE (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WALLACE
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 TOWN PLAZA AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-5140
Mailing Address - Country:US
Mailing Address - Phone:904-395-7771
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:904-395-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20719122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist