Provider Demographics
NPI:1295875110
Name:FORNARIS, LUIS JORGE (DMD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:JORGE
Last Name:FORNARIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14227 SW 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6408
Mailing Address - Country:US
Mailing Address - Phone:305-223-6722
Mailing Address - Fax:305-227-6145
Practice Address - Street 1:14227 SW 42ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6408
Practice Address - Country:US
Practice Address - Phone:305-223-6722
Practice Address - Fax:305-227-6145
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 172301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice