Provider Demographics
NPI:1992498844
Name:CHIDESTER, KEVIN DANIEL (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DANIEL
Last Name:CHIDESTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 BETHWICKE CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-4964
Mailing Address - Country:US
Mailing Address - Phone:978-254-1322
Mailing Address - Fax:
Practice Address - Street 1:200 CORNERSTONE DR STE 200&203
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-8428
Practice Address - Country:US
Practice Address - Phone:435-635-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13421681-8903122300000X
UT13421681-9921122300000X
NC136881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist