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General NPI Number Information
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NPI Number | 1154447589
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Entity Type | Organization
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Legal Business Name | KEITH J WILSON DDS PC
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11166 FAIRFAX BLVD STE 400
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City | FAIRFAX
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State | VA
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Zip | 22030-5017
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Country | US
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Telephone | 703-691-3015
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Fax | 703-691-3016
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Provider Business Mailing Address
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Address Line | 11166 FAIRFAX BLVD STE 400
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City | FAIRFAX
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State | VA
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Zip | 22030-5017
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Country | US
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Telephone | 703-691-3015
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Fax | 703-691-3016
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | DR. KEITH JONATHAN WILSON
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Credential | DDS
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Telephone | 703-691-3015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401008681
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License Number State | VA
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