| NPI | 1154447589 |
|---|---|
| Doing Business As | FAIR LAKES DENTAL SERVICES |
| Entity Type | Organization |
| Authorized Contact | KEITH JONATHAN WILSON Owner President 703-691-3015 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401008681) |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2020-08-22 |