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
StateLicense IDTaxonomies
IN120090841223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200029030Medicaid
IN256430EMedicare PIN
IN200029030Medicaid
IN138700Medicare PIN