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General NPI Number Information
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NPI Number | 1558416883
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Entity Type | Organization
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Legal Business Name | MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 03/26/2009
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Provider Practice Location Address
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Address Line | 7230 ENGLE RD SUITE 301
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City | FORT WAYNE
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State | IN
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Zip | 46804-2209
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Country | US
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Telephone | 260-432-5566
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Fax | 260-432-5567
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Provider Business Mailing Address
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Address Line | 3303 TRIER RD
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City | FORT WAYNE
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State | IN
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Zip | 46815-4768
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Country | US
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Telephone | 260-484-9990
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Fax | 260-484-6573
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL L ICZKOVITZ
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Credential | DDS
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Telephone | 260-484-9990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 54000677
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License Number State | IN
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