Blue Water Dental of St. Johns

Primary specialty

Preferred Provider OrganizationTaxonomy code 305R00000X

License

DN20719 Issued in FL

Legal business name

BLUE WATER DENTAL OF ST. JOHNS

Practice address

460 Town Plaza Ave
Suite 210
Ponte Vedra, FL 32081-5139

Phone

(904) 755-1966

NPI assigned

Aug 23, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. David Wallace Sorensen, D.M.D.

Title

Dentist/Owner

Phone

(904) 755-1966

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1471910400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1471910400000",
    "number": "1821543513",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "334 WILLOW WINDS PKWY",
            "city": "SAINT JOHNS",
            "state": "FL",
            "postal_code": "322597268",
            "telephone_number": "904-755-1966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "460 TOWN PLAZA AVE",
            "address_2": "SUITE 210",
            "city": "PONTE VEDRA",
            "state": "FL",
            "postal_code": "320815139",
            "telephone_number": "904-755-1966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE WATER DENTAL OF ST. JOHNS",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-08-23",
        "last_updated": "2016-08-23",
        "status": "A",
        "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",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.M.D."
    },
    "taxonomies": [
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": "FL",
            "license": "DN20719",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INDIVIDUAL NPI",
            "identifier": "1831508084",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Amanda Bartell, D.P.M.
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• Bella Cesca International, LLC
• Rebecca Bertone, APRN
• Alonzo Carlos Blackmon, D.D.S, M.S.
• Blue Water Health and Wellness LLC
• Bluebird Medical & Wellness Corp
• Bluebird Pediatrics
• Bluewater Wellness Center
• Jennifer Borgio, ATC

• Preferred Provider Organization in Ponte Vedra, FL
• Providers in Ponte Vedra, FL by specialty
• Preferred Provider Organization in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 23, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.