Provider Demographics
NPI:1518496215
Name:MCQUEEN, VAN MICHAEL JR (DDS)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:MICHAEL
Last Name:MCQUEEN
Suffix:JR
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 1:640 N GARLAND AVE # 104
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-3116
Mailing Address - Country:US
Mailing Address - Phone:479-521-2653
Mailing Address - Fax:
Practice Address - Street 1:640 N GARLAND AVE # 104
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701
Practice Address - Country:US
Practice Address - Phone:479-521-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR41781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice