Healthcare Provider Details

I. General information

NPI: 1598781106
Provider Name (Legal Business Name): MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 10/12/2010
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 Number54000677
License Number StateIN

VIII. Authorized Official

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