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General NPI Number Information
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NPI Number | 1104294669
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Entity Type | Organization
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Legal Business Name | BLUEWATER BAY DENTAL, PA
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Dates
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Enumeration Date | 09/14/2015
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Last Update Date | 03/04/2022
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Provider Practice Location Address
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Address Line | 4400 E HIGHWAY 20 STE 101
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City | NICEVILLE
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State | FL
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Zip | 32578-9735
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Country | US
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Telephone | 850-897-4488
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Fax |
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Provider Business Mailing Address
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Address Line | 4400 E HIGHWAY 20 STE 101
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City | NICEVILLE
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State | FL
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Zip | 32578-9735
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Country | US
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Telephone | 850-897-4488
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | OLIVIER BROUTIN
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Credential |
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Telephone | 850-897-4488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN15111
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License Number State | FL
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