MEDICARE: MICHAEL J HAYDUK DDS MSD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	12008530	IN

General Provider Information

NPI Number	:	1518040054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL J HAYDUK DDS MSD PC

Provider Business Mailing Address
First Line	:	450 ST JOHN ROAD
Second Line	:	SUITE 350
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-7347
Country	:	US
Telephone Number	:	219-872-3232
Fax Number	:	219-872-3583

Provider Business Practice Location Address
First Line	:	450 ST JOHN ROAD
Second Line	:	SUITE 350
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-7347
Country	:	US
Telephone Number	:	219-872-3232
Fax Number	:	219-872-3583

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	MICHAEL J HAYDUK
Credential	:	DDS MSD
Telephone Number	:	219-872-3232

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	08/22/2020

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