Provider Demographics
NPI:1578621769
Name:WILSON, KEITH JONATHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:JONATHAN
Last Name:WILSON
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 1:10590 ENDURING FREEDOM DR
Mailing Address - Street 2:US ARMY DENTAL ACTIVITY
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5005
Mailing Address - Country:US
Mailing Address - Phone:315-772-6234
Mailing Address - Fax:
Practice Address - Street 1:10590 ENDURING FREEDOM DR
Practice Address - Street 2:US ARMY DENTAL ACTIVITY
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5005
Practice Address - Country:US
Practice Address - Phone:315-772-6234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist