Provider Demographics
NPI:1538280516
Name:WILKEN, KEITH I (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:I
Last Name:WILKEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7600 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9344
Practice Address - Country:US
Practice Address - Phone:719-539-2587
Practice Address - Fax:719-539-4169
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4375122300000X
VA0401417729122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02073757Medicaid