Zinc oxide (ZnO) nanoparticles (NPs) are widely used as a sunscreen, antibacterial agent, dietary supplement, food additive, and semiconductor material. This review summarizes the biological fate following various exposure routes, toxicological effects, and toxicity mechanism of ZnO NPs in mammals. Furthermore, an approach to reduce the toxicity and biomedical applications of ZnO NPs are discussed. ZnO NPs are mainly absorbed as Zn²⁺ and partially as particles. Regardless of exposure route, elevated Zn concentration in the liver, kidney, lungs, and spleen are observed following ZnO NP exposure, and these are the target organs for ZnO NPs. The liver is the main organ responsible for ZnO NP metabolism and the NPs are mainly excreted in feces and partly in urine. ZnO NPs induce liver damage (oral, intraperitoneal, intravenous, and intratracheal exposure), kidney damage (oral, intraperitoneal, and intravenous exposure) and lung injury (airway exposure). Reactive oxygen species (ROS) generation and induction of oxidative stress may be a major toxicological mechanism for ZnO NPs. ROS are generated by both excess Zn ion release and the particulate effect resulting from the semiconductor or electronic properties of ZnO NPs. ZnO NP toxicity can be reduced by coating their surface with silica, which prevents Zn²⁺ release and ROS generation. Due to their superior characteristics, ZnO NPs are expected to be used for biomedical applications, such as bioimaging, drug delivery, and anticancer agents, and surface coatings and modification will expand the biomedical applications of ZnO NPs further.