Provider Demographics
NPI:1235159930
Name:ICZKOVITZ, MICHAEL L (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:ICZKOVITZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 TRIER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4768
Mailing Address - Country:US
Mailing Address - Phone:260-484-9990
Mailing Address - Fax:260-484-6573
Practice Address - Street 1:3303 TRIER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4768
Practice Address - Country:US
Practice Address - Phone:260-484-9990
Practice Address - Fax:260-484-6573
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120086641223S0112X
MI29010110661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100079980Medicaid
IN000000086698OtherBCBS/ANTHEM
IN100079980Medicaid
IN000000086698OtherBCBS/ANTHEM