Provider Demographics
NPI:1649316183
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 1:358 E CHICAGO ST
Practice Address - Street 2:SUITE 200-A
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2072
Practice Address - Country:US
Practice Address - Phone:517-279-1730
Practice Address - Fax:517-279-1736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI168921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U02371Medicare UPIN
MIOM84650Medicare ID - Type UnspecifiedMEDICARE