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NPI Code Detail

MEDICARE: MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C

MEDICARE: MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C
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
11223S0112XOral and Maxillofacial Surgery (Dentist)54000677IN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1598781106
Entity Type Code : Organization
Provider Name (Legal Business Name) : MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C
Provider Business Mailing Address
First Line : 3303 TRIER RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46815-4768
Country : US
Telephone Number : 260-484-9990
Fax Number : 260-484-6573
Provider Business Practice Location Address
First Line : 3303 TRIER RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46815-4768
Country : US
Telephone Number : 260-484-9990
Fax Number : 260-484-6573
Authorized Official
Title or Position : PRESIDENT
Name : MICHAEL L. ICZKOVITZ
Credential : D.D.S.
Telephone Number : 260-484-9990
Provider Enumeration Date : 07/15/2006
Last Update Date : 10/12/2010

Similar Medicare Providers

1235159930 — MICHAEL L ICZKOVITZ D.D.S.
Practice Location Address:
3303 TRIER RD
FORT WAYNE, IN
46815-4768
Practice Phone: 260-484-9990
Practice Fax: 260-484-6573
1649290354 — ROBERT E. BRAUN D.D.S.
Practice Location Address:
3303 TRIER RD
FORT WAYNE, IN
46815-4768
Practice Phone: 260-484-9990
Practice Fax: 260-484-6573
1437179140 — DR. ROBERT L REIFEIS JR. D.D.S.
Practice Location Address:
3303 TRIER RD
FORT WAYNE, IN
46815-4768
Practice Phone: 260-999-4929
Practice Fax: 260-755-1086
1710062690 — NICHOLAS L. RICO, M.D., P.C.
Practice Location Address:
3303 TRIER RD STE 1
FORT WAYNE, IN
46815-4768
Practice Phone: 260-483-4260
Practice Fax: 260-483-6066
1942359393 — DR. JACK JOSEPH WEHRLY DDS
Practice Location Address:
3303 TRIER RD
FORT WAYNE, IN
46815-4768
Practice Phone: 260-484-4438
Practice Fax: 260-482-6204
1982830766 — DR. YASH KUMAR SINGH DMD, MD
Practice Location Address:
3303 TRIER RD
FORT WAYNE, IN
46815-4768
Practice Phone: 260-484-9990
Practice Fax: 260-484-6573

Directions to “MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C ” Practice Location

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