Provider Demographics
NPI:1225096712
Name:WYCKOFF, KEITH G (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:G
Last Name:WYCKOFF
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 W 6TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-4703
Mailing Address - Country:US
Mailing Address - Phone:912-767-6735
Mailing Address - Fax:912-767-5425
Practice Address - Street 1:351 W 6TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-4703
Practice Address - Country:US
Practice Address - Phone:912-767-6735
Practice Address - Fax:912-767-5425
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1022370001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice