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General NPI Number Information
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NPI Number | 1609315480
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Entity Type | Organization
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Legal Business Name | PONY EXPRESS DENTAL LLC
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Dates
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Enumeration Date | 02/14/2017
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Last Update Date | 03/16/2017
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Provider Practice Location Address
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Address Line | 1308 E. EAGLE MOUNTAIN BLVD
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City | EAGLE MOUNTAIN
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State | UT
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Zip | 84005
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Country | US
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Telephone | 801-876-7669
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Fax |
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Provider Business Mailing Address
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Address Line | 219 E 12300 S SUITE I-5
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City | DRAPER
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State | UT
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Zip | 84020-6970
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Country | US
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Telephone | 801-789-7669
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Fax |
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Authorized Official
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Title or Position | COO
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Name | DR. MICHAEL S TORNOW
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Credential | DMD
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Telephone | 505-947-4252
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 5015649
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License Number State | UT
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