Provider Demographics
NPI:1932714516
Name:PONY EXPRESS DENTAL OF ALPINE
Entity type:Organization
Organization Name:PONY EXPRESS DENTAL OF ALPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE AND OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-845-7760
Mailing Address - Street 1:5396 W DAYBREAK PKWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-5900
Mailing Address - Country:US
Mailing Address - Phone:801-845-7760
Mailing Address - Fax:
Practice Address - Street 1:20 W MAIN STREET CT STE 100
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-1889
Practice Address - Country:US
Practice Address - Phone:801-845-7760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental