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General NPI Number Information
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NPI Number | 1932198801
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Entity Type | Individual
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Provider Name | KEITH STANLEY WICKIZER D.M.D., M.S., A.B.O.
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Gender | Male
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Dates
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Enumeration Date | 10/13/2005
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Last Update Date | 04/15/2008
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Provider Practice Location Address
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Address Line | 100 OMALLEY DR UNIT B
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City | SUMMERVILLE
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State | SC
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Zip | 29483-5635
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Country | US
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Telephone | 843-261-0142
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Fax | 843-261-0125
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Provider Business Mailing Address
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Address Line | 100 OMALLEY DR UNIT B
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City | SUMMERVILLE
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State | SC
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Zip | 29483-5635
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Country | US
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Telephone | 843-261-0142
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Fax | 843-261-0125
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4227
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 0657
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License Number State | SC
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