Provider Demographics
NPI: | 1245240399 |
---|---|
Name: | STRONCZEK, MICHAEL J (DDS) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MICHAEL |
Middle Name: | J |
Last Name: | STRONCZEK |
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: | 4606 D EAST STATE BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT WAYNE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46815-6963 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 260-423-2340 |
Mailing Address - Fax: | 260-422-5342 |
Practice Address - Street 1: | 7845 CARNEGIE BLVD |
Practice Address - Street 2: | |
Practice Address - City: | FORT WAYNE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46804-5792 |
Practice Address - Country: | US |
Practice Address - Phone: | 260-423-2340 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-09 |
Last Update Date: | 2020-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 12009084 | 1223S0112X, 204E00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 204E00000X | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | |
No | 1223S0112X | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 200029030 | Medicaid | |
IN | 256430E | Medicare PIN | |
IN | 200029030 | Medicaid | |
IN | 138700 | Medicare PIN |