Provider Demographics
NPI:1154371342
Name:WUNSCH, KEITH A (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:WUNSCH
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 1:6348 DARING PRINCE WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-6040
Mailing Address - Country:US
Mailing Address - Phone:240-264-6069
Mailing Address - Fax:
Practice Address - Street 1:8472 SIMMOND ST
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5700
Practice Address - Country:US
Practice Address - Phone:301-677-7971
Practice Address - Fax:301-677-6678
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0139561223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics