Provider Demographics
NPI:1104347061
Name:PONY EXPRESS DENTAL DAYBREAK, LLC
Entity type:Organization
Organization Name:PONY EXPRESS DENTAL DAYBREAK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TORNOW
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-876-7669
Mailing Address - Street 1:1308 E EAGLE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-5412
Mailing Address - Country:US
Mailing Address - Phone:801-876-7669
Mailing Address - Fax:801-407-1782
Practice Address - Street 1:5396 W DAYBREAK PARKWAY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009
Practice Address - Country:US
Practice Address - Phone:801-876-7669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5015649-8903261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental