Healthcare Provider Details

I. General information

NPI: 1659369700
Provider Name (Legal Business Name): MICHAEL S TORNOW DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4342 E PONY EXPRESS PKWY
EAGLE MOUNTAIN UT
84005-5773
US

IV. Provider business mailing address

4342 E PONY EXPRESS PKWY
EAGLE MOUNTAIN UT
84005-5773
US

V. Phone/Fax

Practice location:
  • Phone: 505-947-4253
  • Fax: 385-449-9948
Mailing address:
  • Phone: 505-947-4253
  • Fax: 385-449-9948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number50156499924
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD2287
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: