Healthcare Provider Details

I. General information

NPI: 1104153634
Provider Name (Legal Business Name): KRISTY FORNETTI D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SOUTH CASE STREET
NORWAY MI
49870-0069
US

IV. Provider business mailing address

PO BOX 69
NORWAY MI
49870-0069
US

V. Phone/Fax

Practice location:
  • Phone: 906-563-8010
  • Fax: 906-563-5862
Mailing address:
  • Phone: 906-563-8010
  • Fax: 906-563-5862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberL1373793
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: