Healthcare Provider Details

I. General information

NPI: 1558416883
Provider Name (Legal Business Name): MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7230 ENGLE RD SUITE 301
FORT WAYNE IN
46804-2209
US

IV. Provider business mailing address

3303 TRIER RD
FORT WAYNE IN
46815-4768
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-5566
  • Fax: 260-432-5567
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 Number54000677
License Number StateIN

VIII. Authorized Official

Name: DR. MICHAEL L ICZKOVITZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 260-484-9990