Healthcare Provider Details

I. General information

NPI: 1841456720
Provider Name (Legal Business Name): MARIA LENA FORNATORA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N BROAD ST
PHILADELPHIA PA
19140-5007
US

IV. Provider business mailing address

1044 JENKINTOWN RD
JENKINTOWN PA
19046-3845
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-4202
  • Fax:
Mailing address:
  • Phone: 215-887-7997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDS029718L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: