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General NPI Number Information
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NPI Number | 1821543513
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Entity Type | Organization
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Legal Business Name | BLUE WATER DENTAL OF ST. JOHNS
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Dates
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Enumeration Date | 08/23/2016
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Last Update Date | 08/23/2016
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Provider Practice Location Address
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Address Line | 460 TOWN PLAZA AVE SUITE 210
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City | PONTE VEDRA
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State | FL
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Zip | 32081-5139
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Country | US
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Telephone | 904-755-1966
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Fax |
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Provider Business Mailing Address
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Address Line | 334 WILLOW WINDS PKWY
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City | SAINT JOHNS
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State | FL
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Zip | 32259-7268
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Country | US
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Telephone | 904-755-1966
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. DAVID WALLACE SORENSEN
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Credential | D.M.D.
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Telephone | 904-755-1966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | DN20719
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License Number State | FL
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