Healthcare Provider Details

I. General information

NPI: 1154371342
Provider Name (Legal Business Name): KEITH A. WUNSCH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8472 SIMMOND ST
FORT MEADE MD
20755-5700
US

IV. Provider business mailing address

6348 DARING PRINCE WAY
COLUMBIA MD
21044-6040
US

V. Phone/Fax

Practice location:
  • Phone: 301-677-7971
  • Fax: 301-677-6678
Mailing address:
  • Phone: 240-264-6069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number013956
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: