| Fair Lakes Dental Services | |
|
11166 Fairfax Blvd Ste 400 Fairfax VA 22030-5017 | |
| (703) 691-3015 | |
| (703) 691-3016 |
| Full Name | Fair Lakes Dental Services |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 11166 Fairfax Blvd Ste 400, Fairfax, Virginia |
| Authorized Official Name and Position | Keith Jonathan Wilson (OWNER PRESIDENT) |
| Authorized Official Contact | 7036913015 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Fair Lakes Dental Services 11166 Fairfax Blvd Ste 400 Fairfax VA 22030-5017 Ph: (703) 691-3015 | Fair Lakes Dental Services 11166 Fairfax Blvd Ste 400 Fairfax VA 22030-5017 Ph: (703) 691-3015 |
| NPI Number | 1154447589 |
|---|---|
| Provider Enumeration Date | 03/21/2007 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1154447589 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 0401008681 (Virginia) | Primary |
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