Healthcare Provider Details

I. General information

NPI: 1174144349
Provider Name (Legal Business Name): KEVIN SHE-WAI CHAN DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 LAKE BOONE TRL STE 2
RALEIGH NC
27607-7511
US

IV. Provider business mailing address

1501 CATCH FLY LN
DURHAM NC
27713-2556
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-3949
  • Fax: 919-787-7634
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11851
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number11851
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: