Organization
BLUE WATER DENTAL OF ST. JOHNS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DAVID WALLACE SORENSEN D.M.D. (DENTIST/OWNER)
(904) 755-1966
Entity
Organization
Contact information
Practice address
460 TOWN PLAZA AVE, SUITE 210, PONTE VEDRA, FL 32081-5139
(904) 755-1966
Mailing address
334 WILLOW WINDS PKWY, SAINT JOHNS, FL 32259-7268
(904) 755-1966
Taxonomy
Speciality
Code
Description
License number
State
305R00000X
Preferred Provider Organization
Primary
DN20719
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1831508084
INDIVIDUAL NPI
FL
Enumeration date
08/23/2016
Last updated
08/23/2016
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