Organization
MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL L ICZKOVITZ DDS (PRESIDENT)
(260) 484-9990
Entity
Organization
Contact information
Practice address
7230 ENGLE RD, SUITE 301, FORT WAYNE, IN 46804-2209
(260) 432-5566
(260) 432-5567
Mailing address
3303 TRIER RD, FORT WAYNE, IN 46815-4768
(260) 484-9990
(260) 484-6573
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
54000677
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200147450
—
IN
Enumeration date
01/25/2007
Last updated
03/26/2009
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