Healthcare Provider Details

I. General information

NPI: 1992498844
Provider Name (Legal Business Name): KEVIN DANIEL CHIDESTER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6807 KNIGHTDALE BLVD STE E
KNIGHTDALE NC
27545-6563
US

IV. Provider business mailing address

3012 BETHWICKE CT
RALEIGH NC
27604-4964
US

V. Phone/Fax

Practice location:
  • Phone: 919-438-3933
  • Fax: 919-850-5533
Mailing address:
  • Phone: 978-254-1322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number13421681-9921
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number13421681-8903
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13688
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: