Provider Demographics
NPI:1457608986
Name:DENTAL CENTER OF HERNDON
Entity Type:Organization
Organization Name:DENTAL CENTER OF HERNDON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:QIU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-318-7200
Mailing Address - Street 1:1110 ELDEN ST.
Mailing Address - Street 2:SUITE E108
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170
Mailing Address - Country:US
Mailing Address - Phone:703-318-7200
Mailing Address - Fax:703-318-8668
Practice Address - Street 1:1110 ELDEN ST.
Practice Address - Street 2:SUITE E108
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170
Practice Address - Country:US
Practice Address - Phone:703-318-7200
Practice Address - Fax:703-318-8668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4011024281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty