Provider Demographics
NPI:1811041239
Name:TED A FORNETTI DDS PC
Entity Type:Organization
Organization Name:TED A FORNETTI DDS PC
Other - Org Name:TED J FORNETTI DDS PC
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORNETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-774-4444
Mailing Address - Street 1:1115 SOUTH HEMLOCK
Mailing Address - Street 2:SUITE 1
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801
Mailing Address - Country:US
Mailing Address - Phone:906-774-4444
Mailing Address - Fax:906-774-6949
Practice Address - Street 1:1115 SOUTH HEMLOCK
Practice Address - Street 2:SUITE 1
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801
Practice Address - Country:US
Practice Address - Phone:906-774-4444
Practice Address - Fax:906-774-6949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010178981223G0001X
MI29010194081223G0001X
MI104221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty