Healthcare Provider Details

I. General information

NPI: 1609315480
Provider Name (Legal Business Name): PONY EXPRESS DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 E. EAGLE MOUNTAIN BLVD
EAGLE MOUNTAIN UT
84005
US

IV. Provider business mailing address

219 E 12300 S SUITE I-5
DRAPER UT
84020-6970
US

V. Phone/Fax

Practice location:
  • Phone: 801-876-7669
  • Fax:
Mailing address:
  • Phone: 801-789-7669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5015649
License Number StateUT

VIII. Authorized Official

Name: DR. MICHAEL S TORNOW
Title or Position: COO
Credential: DMD
Phone: 505-947-4252