Provider Demographics
NPI:1083861348
Name:FORNETTI, THEODORE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:A
Last Name:FORNETTI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 S HEMLOCK ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3800
Mailing Address - Country:US
Mailing Address - Phone:906-774-2776
Mailing Address - Fax:906-774-6949
Practice Address - Street 1:1115 S HEMLOCK ST
Practice Address - Street 2:SUITE 1
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3800
Practice Address - Country:US
Practice Address - Phone:906-774-2776
Practice Address - Fax:906-774-6949
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010178981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice