Provider Demographics
NPI:1609315480
Name:PONY EXPRESS DENTAL LLC
Entity Type:Organization
Organization Name:PONY EXPRESS DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:TORNOW
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-947-4252
Mailing Address - Street 1:219 E 12300 S
Mailing Address - Street 2:SUITE I-5
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6970
Mailing Address - Country:US
Mailing Address - Phone:801-789-7669
Mailing Address - Fax:
Practice Address - Street 1:1308 E. EAGLE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005
Practice Address - Country:US
Practice Address - Phone:801-876-7669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE MOUNTAIN HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-14
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5015649261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental