Healthcare Provider Details

I. General information

NPI: 1568127017
Provider Name (Legal Business Name): NIKOLAS MARK WASYLYK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 S 4TH ST
TERRE HAUTE IN
47802-5543
US

IV. Provider business mailing address

3630 S 4TH ST
TERRE HAUTE IN
47802-5543
US

V. Phone/Fax

Practice location:
  • Phone: 812-814-9245
  • Fax: 812-226-0370
Mailing address:
  • Phone: 484-763-0747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12013869A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: