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
358 E CHICAGO ST, SUITE 200-A, COLDWATER, MI 49036-2072
(517) 279-1730
(517) 279-1736
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
16892
MI
Other
Enumeration date
01/30/2007
Last updated
03/26/2009
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