Provider Demographics
NPI:1902196702
Name:FORNETTI, DANIEL JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOHN
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 1:100 S. STEPHENSON AVE.
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801
Mailing Address - Country:US
Mailing Address - Phone:906-774-0100
Mailing Address - Fax:905-774-8904
Practice Address - Street 1:100 S. STEPHENSON AVE.
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801
Practice Address - Country:US
Practice Address - Phone:906-774-0100
Practice Address - Fax:905-774-8904
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011018508122300000X
MI2901020539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist