MEDICARE: KEITH J WILSON DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401008681	VA

General Provider Information

NPI Number	:	1154447589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH J WILSON DDS PC

Provider Business Mailing Address
First Line	:	11166 FAIRFAX BLVD STE 400
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-5017
Country	:	US
Telephone Number	:	703-691-3015
Fax Number	:	703-691-3016

Provider Business Practice Location Address
First Line	:	11166 FAIRFAX BLVD STE 400
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-5017
Country	:	US
Telephone Number	:	703-691-3015
Fax Number	:	703-691-3016

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	DR. KEITH JONATHAN WILSON
Credential	:	DDS
Telephone Number	:	703-691-3015

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	08/22/2020

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