Provider Demographics
NPI:1447518378
Name:CHAN, KEVIN LEE (KEVIN CHAN)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEE
Last Name:CHAN
Suffix:
Gender:M
Credentials:KEVIN CHAN
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:LEE
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:210 CANAL ST
Mailing Address - Street 2:603
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4155
Mailing Address - Country:US
Mailing Address - Phone:212-349-9682
Mailing Address - Fax:212-349-1772
Practice Address - Street 1:210 CANAL ST
Practice Address - Street 2:603
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4155
Practice Address - Country:US
Practice Address - Phone:212-349-9682
Practice Address - Fax:212-349-1772
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-29
Last Update Date:2012-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044175122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist