Provider Demographics
NPI:1467595363
Name:FAST, JOEL N (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:N
Last Name:FAST
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 1:20673 SW ROY ROGERS RD
Mailing Address - Street 2:STE. 201
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9222
Mailing Address - Country:US
Mailing Address - Phone:503-925-0588
Mailing Address - Fax:503-925-0418
Practice Address - Street 1:20673 SW ROY ROGERS RD
Practice Address - Street 2:STE. 201
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9222
Practice Address - Country:US
Practice Address - Phone:503-925-0588
Practice Address - Fax:503-925-0418
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000106711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5051677Medicaid
WA0214008OtherLABOR & INDUSTRIES ID #