Healthcare Provider Details

I. General information

NPI: 1174012876
Provider Name (Legal Business Name): PONY EXRESS ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5396 W DAYBREAK PKWY
SOUTH JORDAN UT
84009-5900
US

IV. Provider business mailing address

5396 W DAYBREAK PKWY
SOUTH JORDAN UT
84009-5900
US

V. Phone/Fax

Practice location:
  • Phone: 801-614-7669
  • Fax:
Mailing address:
  • Phone: 801-614-7669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: AMANDA GARNER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 801-614-7669