Provider Demographics
NPI:1104153634
Name:FORNETTI, KRISTY (DDS)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:FORNETTI
Suffix:
Gender:F
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:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:MI
Mailing Address - Zip Code:49870-0069
Mailing Address - Country:US
Mailing Address - Phone:906-563-8010
Mailing Address - Fax:906-563-5862
Practice Address - Street 1:800 SOUTH CASE STREET
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:MI
Practice Address - Zip Code:49870-0069
Practice Address - Country:US
Practice Address - Phone:906-563-8010
Practice Address - Fax:906-563-5862
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL13737931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice