Provider Demographics
NPI:1467507798
Name:MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C
Entity Type:Organization
Organization Name:MIDWEST ORAL AND MAXILLOFACIAL SURGERY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ICZKOVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-484-9990
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 1:516 N LINE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1230
Practice Address - Country:US
Practice Address - Phone:260-244-4007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN540006771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200147450Medicaid
IN924690Medicare ID - Type UnspecifiedMEDICARE