MEDICARE: MICHAEL S TORNOW DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DD2287	NM
2	122300000X	Dentist	50156499924	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	201438729	OTHER	NM	TAX ID

General Provider Information

NPI Number	:	1659369700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL S TORNOW DMD

Provider Business Mailing Address
First Line	:	4342 E PONY EXPRESS PKWY
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-5773
Country	:	US
Telephone Number	:	505-947-4253
Fax Number	:	385-449-9948

Provider Business Practice Location Address
First Line	:	4342 E PONY EXPRESS PKWY
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-5773
Country	:	US
Telephone Number	:	505-947-4253
Fax Number	:	385-449-9948

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	07/05/2023

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