# MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1598781106
- **Authorized official:** MICHAEL L. ICZKOVITZ D.D.S. (PRESIDENT)
- **Authorized official phone:** (260) 484-9990

## Contact information

- **Practice address:** 3303 TRIER RD, FORT WAYNE, IN 46815-4768
- **Practice address phone:** (260) 484-9990
- **Practice address fax:** (260) 484-6573
- **Mailing address:** 3303 TRIER RD, FORT WAYNE, IN 46815-4768
- **Mailing address phone:** (260) 484-9990
- **Mailing address fax:** (260) 484-6573

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 54000677 | IN | Yes |

## Other

- **Enumeration date:** 07/15/2006
- **Last updated:** 10/12/2010