Provider Demographics
NPI:1801291521
Name:QUEEN, JAY BRIAN (DDS)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:BRIAN
Last Name:QUEEN
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 1:102 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:
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:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA401007661122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist