Healthcare Provider Details

I. General information

NPI: 1235159930
Provider Name (Legal Business Name): MICHAEL L ICZKOVITZ D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 TRIER RD
FORT WAYNE IN
46815-4768
US

IV. Provider business mailing address

3303 TRIER RD
FORT WAYNE IN
46815-4768
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-9990
  • Fax: 260-484-6573
Mailing address:
  • Phone: 260-484-9990
  • Fax: 260-484-6573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12008664
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901011066
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: