Provider Demographics
NPI:1679458913
Name:FORNATTO, NICHOLAS (DMD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:FORNATTO
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 1:1720 W LE MOYNE ST # 201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2133
Mailing Address - Country:US
Mailing Address - Phone:630-531-7528
Mailing Address - Fax:
Practice Address - Street 1:9101 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1804
Practice Address - Country:US
Practice Address - Phone:708-419-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019036134122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist