1821543513 NPI number — BLUE WATER DENTAL OF ST. JOHNS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821543513 NPI number — BLUE WATER DENTAL OF ST. JOHNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE WATER DENTAL OF ST. JOHNS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821543513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
334 WILLOW WINDS PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOHNS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32259-7268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-755-1966
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 TOWN PLAZA AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
PONTE VEDRA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32081-5139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-755-1966
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SORENSEN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
WALLACE
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
904-755-1966

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  DN20719 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1831508084 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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