Provider Demographics
NPI:1174508196
Name:J. BRIAN QUEEN, DDS, PC
Entity Type:Organization
Organization Name:J. BRIAN QUEEN, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-689-2480
Mailing Address - Street 1:102 ELDEN ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4868
Mailing Address - Country:US
Mailing Address - Phone:703-689-2480
Mailing Address - Fax:703-689-2482
Practice Address - Street 1:102 ELDEN ST
Practice Address - Street 2:SUITE 20
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4868
Practice Address - Country:US
Practice Address - Phone:703-689-2480
Practice Address - Fax:703-689-2482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010076611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty