Healthcare Provider Details

I. General information

NPI: 1669039244
Provider Name (Legal Business Name): TEDI VATNIKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LIMESTONE RD STE 208
WILMINGTON DE
19808-2005
US

IV. Provider business mailing address

4420 LIMESTONE RD STE 208
WILMINGTON DE
19808-2005
US

V. Phone/Fax

Practice location:
  • Phone: 302-274-0130
  • Fax:
Mailing address:
  • Phone: 302-274-0130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS042149
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS042149
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberG1-0011581
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: