Provider Demographics
NPI:1891813358
Name:QIU, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:QIU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 ELDEN ST STE E108
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5529
Mailing Address - Country:US
Mailing Address - Phone:703-318-7200
Mailing Address - Fax:703-318-8668
Practice Address - Street 1:1110 ELDEN ST STE E108
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5529
Practice Address - Country:US
Practice Address - Phone:703-318-7200
Practice Address - Fax:703-318-8668
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4011024281223G0001X
VA4014102571223G0001X
VA4014107401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice