Keith J Wilson DDS PC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

0401008681 Issued in VA

Legal business name

KEITH J WILSON DDS PC

Doing business as

FAIR LAKES DENTAL SERVICES

Practice address

11166 Fairfax Blvd Ste 400
Fairfax, VA 22030-5017

Phone

(703) 691-3015

Fax

(703) 691-3016

NPI assigned

Mar 21, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Keith Jonathan Wilson, DDS

Title

Owner President

Phone

(703) 691-3015

Specialties & licenses 1

Addresses

Other names 1

• FAIR LAKES DENTAL SERVICES Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174435200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1154447589",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11166 FAIRFAX BLVD STE 400",
            "city": "FAIRFAX",
            "state": "VA",
            "postal_code": "220305017",
            "telephone_number": "703-691-3015",
            "fax_number": "703-691-3016"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11166 FAIRFAX BLVD STE 400",
            "city": "FAIRFAX",
            "state": "VA",
            "postal_code": "220305017",
            "telephone_number": "703-691-3015",
            "fax_number": "703-691-3016"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KEITH J WILSON DDS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-21",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "KEITH",
        "authorized_official_middle_name": "JONATHAN",
        "authorized_official_title_or_position": "OWNER PRESIDENT",
        "authorized_official_telephone_number": "703-691-3015",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "VA",
            "license": "0401008681",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "FAIR LAKES DENTAL SERVICES",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Mary Kathleen Keenan, LPC
• Kazumi Keener, OT
• Samantha Anne Kehn
• Daniel Edward Keim, M.D.
• Kathryn Gray Keiser, M.S.
• Keith K. Ewell, PH.D.
• Courtney Ann Kelchlin, PHARMD
• Joan Kelleher
• Barbara B Keller, PH.D.
• Kaitlyn Rae Kellermeyer

• General Practice Dentistry in Fairfax, VA
• Providers in Fairfax, VA by specialty
• General Practice Dentistry in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.