Provider Demographics
NPI:1932198801
Name:WICKIZER, KEITH STANLEY (DMD, MS, ABO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:STANLEY
Last Name:WICKIZER
Suffix:
Gender:M
Credentials:DMD, MS, ABO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 OMALLEY DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-5635
Mailing Address - Country:US
Mailing Address - Phone:843-261-0142
Mailing Address - Fax:843-261-0125
Practice Address - Street 1:100 OMALLEY DR UNIT B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-5635
Practice Address - Country:US
Practice Address - Phone:843-261-0142
Practice Address - Fax:843-261-0125
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4227122300000X
SC06571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist