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  5. BLUE WATER DENTAL OF ST. JOHNS, LLC

BLUE WATER DENTAL OF ST. JOHNS, LLC

Company Details

Entity Name: BLUE WATER DENTAL OF ST. JOHNS, LLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Co.
Status: Active
Date Filed: 08 Feb 2016 (9 years ago)
Document Number: L16000026801
FEI/EIN Number 811397766
Address: 460 TOWN PLAZA AVENUE, PONTE VEDRA, FL, 32081, US
Mail Address: 460 TOWN PLAZA AVENUE, PONTE VEDRA, FL, 32081, US
ZIP code: 32081
County: St. Johns
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1821543513 2016-08-23 2016-08-23 334 WILLOW WINDS PKWY, SAINT JOHNS, FL, 322597268, US 460 TOWN PLAZA AVE, SUITE 210, PONTE VEDRA, FL, 320815139, US

Contacts
Phone +1 904-755-1966

Authorized person
Name DR. DAVID WALLACE SORENSEN
Role DENTIST/OWNER
Phone 9047551966

Taxonomy
Taxonomy Code 305R00000X - Preferred Provider Organization
License Number DN20719
State FL
Is Primary Yes

Other Provider Identifiers
Issuer INDIVIDUAL NPI
Number 1831508084
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
BLUE WATER DENTAL OF ST. JOHNS 401(K) PLAN 2023 811397766 2024-10-03 BLUE WATER DENTAL OF ST. JOHNS 13
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621210
Sponsor’s telephone number 9047551966
Plan sponsor’s address 460 TOWN PLAZA AVE STE 210, PONTE VEDRA, FL, 32081

Signature of
Role Plan administrator
Date 2024-10-03
Name of individual signing ALLISON BRECHER
Valid signature Filed with authorized/valid electronic signature
BLUE WATER DENTAL OF ST. JOHNS 401(K) PLAN 2022 811397766 2023-09-28 BLUE WATER DENTAL OF ST. JOHNS 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621210
Sponsor’s telephone number 9047551966
Plan sponsor’s address 460 TOWN PLAZA AVE STE 210, PONTE VEDRA, FL, 32081

Signature of
Role Plan administrator
Date 2023-09-28
Name of individual signing ALLISON BRECHER
Valid signature Filed with authorized/valid electronic signature
BLUE WATER DENTAL OF ST. JOHNS 401(K) PLAN 2021 811397766 2022-10-03 BLUE WATER DENTAL OF ST. JOHNS 10
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621210
Sponsor’s telephone number 9047551966
Plan sponsor’s address 460 TOWN PLAZA AVE STE 210, PONTE VEDRA, FL, 32081

Signature of
Role Plan administrator
Date 2022-10-03
Name of individual signing ALLISON BRECHER
Valid signature Filed with authorized/valid electronic signature
BLUE WATER DENTAL OF ST. JOHNS 401(K) PLAN 2021 811397766 2022-10-03 BLUE WATER DENTAL OF ST. JOHNS 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621210
Sponsor’s telephone number 9047551966
Plan sponsor’s address 460 TOWN PLAZA AVE STE 210, PONTE VEDRA, FL, 32081

Signature of
Role Plan administrator
Date 2022-10-03
Name of individual signing ALLISON BRECHER
Valid signature Filed with authorized/valid electronic signature
BLUE WATER DENTAL OF ST. JOHNS 401(K) PLAN 2021 811397766 2022-10-03 BLUE WATER DENTAL OF ST. JOHNS 10
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621210
Sponsor’s telephone number 9047551966
Plan sponsor’s address 460 TOWN PLAZA AVE STE 210, PONTE VEDRA, FL, 32081

Signature of
Role Plan administrator
Date 2022-10-03
Name of individual signing ALLISON BRECHER
Valid signature Filed with authorized/valid electronic signature
BLUE WATER DENTAL OF ST. JOHNS 401(K) PLAN 2021 811397766 2022-10-03 BLUE WATER DENTAL OF ST. JOHNS 10
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621210
Sponsor’s telephone number 9047551966
Plan sponsor’s address 460 TOWN PLAZA AVE STE 210, PONTE VEDRA, FL, 32081

Signature of
Role Plan administrator
Date 2022-10-03
Name of individual signing ALLISON BRECHER
Valid signature Filed with authorized/valid electronic signature
BLUE WATER DENTAL OF ST. JOHNS 401(K) PLAN 2021 811397766 2022-10-03 BLUE WATER DENTAL OF ST. JOHNS 10
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621210
Sponsor’s telephone number 9047551966
Plan sponsor’s address 460 TOWN PLAZA AVE STE 210, PONTE VEDRA, FL, 32081

Signature of
Role Plan administrator
Date 2022-10-03
Name of individual signing ALLISON BRECHER
Valid signature Filed with authorized/valid electronic signature
BLUE WATER DENTAL OF ST. JOHNS 401(K) PLAN 2020 811397766 2021-10-08 BLUE WATER DENTAL OF ST. JOHNS 8
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621210
Sponsor’s telephone number 9047551966
Plan sponsor’s address 460 TOWN PLAZA AVE STE 210, PONTE VEDRA, FL, 32081

Signature of
Role Plan administrator
Date 2021-10-08
Name of individual signing ALLISON BRECHER
Valid signature Filed with authorized/valid electronic signature
BLUE WATER DENTAL OF ST. JOHNS 401(K) PLAN 2019 811397766 2020-09-09 BLUE WATER DENTAL OF ST. JOHNS 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621210
Sponsor’s telephone number 9047551966
Plan sponsor’s address 460 TOWN PLAZA AVE STE 210, PONTE VEDRA, FL, 32081

Signature of
Role Plan administrator
Date 2020-09-09
Name of individual signing CHRISTINA OWEN
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
SORENSEN DAVID WD.M.D. Agent 460 TOWN PLAZA AVENUE, PONTE VEDRA, FL, 32081

President

Name Role Address
SORENSEN DAVID WD.M.D. President 460 TOWN PLAZA AVENUE, PONTE VEDRA, FL, 32081

Events

Event Type Filed Date Value Description
CHANGE OF PRINCIPAL ADDRESS 2017-01-28 460 TOWN PLAZA AVENUE, Suite 210, PONTE VEDRA, FL 32081 No data
CHANGE OF MAILING ADDRESS 2017-01-28 460 TOWN PLAZA AVENUE, Suite 210, PONTE VEDRA, FL 32081 No data
REGISTERED AGENT ADDRESS CHANGED 2017-01-28 460 TOWN PLAZA AVENUE, Suite 210, PONTE VEDRA, FL 32081 No data

Documents

Name Date
ANNUAL REPORT 2024-03-08
ANNUAL REPORT 2023-04-24
ANNUAL REPORT 2022-03-04
ANNUAL REPORT 2021-03-03
ANNUAL REPORT 2020-02-06
ANNUAL REPORT 2019-04-10
ANNUAL REPORT 2018-04-14
ANNUAL REPORT 2017-01-28
Florida Limited Liability 2016-02-08

Related by officers

SORENSEN DAVID WD.M.D.

LAZK VENTURES, LLC

Related by address

460 TOWN PLAZA AVENUE, PONTE VEDRA, FL, 32081, US

PONTE VEDRA COUNSELING & WELLNESS LLC

460 TOWN PLAZA AVENUE, PONTE VEDRA, FL, 32081, US

PONTE VEDRA COUNSELING & WELLNESS LLC

Date of last update: 01 Feb 2025

Sources: Florida Department of State

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