Healthcare Provider Details

I. General information

NPI: 1770637779
Provider Name (Legal Business Name): K. KEVIN NESHAT, DDS, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8305 FALLS OF NEUSE RD SUITE 105
RALEIGH NC
27615-3546
US

IV. Provider business mailing address

8305 FALLS OF NEUSE RD SUITE 105
RALEIGH NC
27615-3546
US

V. Phone/Fax

Practice location:
  • Phone: 919-841-1720
  • Fax: 919-841-1725
Mailing address:
  • Phone: 919-841-1720
  • Fax: 919-841-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number6503
License Number StateNC

VIII. Authorized Official

Name: DR. KHASHAYAR KEVIN NESHAT
Title or Position: PRESIDENT
Credential: DDS, MD
Phone: 919-841-1720