# KEITH J WILSON DDS PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** FAIR LAKES DENTAL SERVICES
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154447589
- **Authorized official:** DR. KEITH JONATHAN WILSON DDS (OWNER PRESIDENT)
- **Authorized official phone:** (703) 691-3015

## Contact information

- **Practice address:** 11166 FAIRFAX BLVD STE 400, FAIRFAX, VA 22030-5017
- **Practice address phone:** (703) 691-3015
- **Practice address fax:** (703) 691-3016
- **Mailing address:** 11166 FAIRFAX BLVD STE 400, FAIRFAX, VA 22030-5017
- **Mailing address phone:** (703) 691-3015
- **Mailing address fax:** (703) 691-3016

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 0401008681 | VA | Yes |

## Other

- **Enumeration date:** 03/21/2007
- **Last updated:** 08/22/2020