1174508196 NPI number — J. BRIAN QUEEN, DDS, PC

Table of content: (NPI 1174508196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174508196 NPI number — J. BRIAN QUEEN, DDS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J. BRIAN QUEEN, DDS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174508196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 ELDEN ST
Provider Second Line Business Mailing Address:
SUITE 20
Provider Business Mailing Address City Name:
HERNDON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20170-4868
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-689-2480
Provider Business Mailing Address Fax Number:
703-689-2482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 ELDEN ST
Provider Second Line Business Practice Location Address:
SUITE 20
Provider Business Practice Location Address City Name:
HERNDON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20170-4868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-689-2480
Provider Business Practice Location Address Fax Number:
703-689-2482
Provider Enumeration Date:
12/13/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
QUEEN
Authorized Official First Name:
J.
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
703-689-2480

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  0401007661 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)