Provider Demographics
NPI:1558397729
Name:FAST, REBECCA J (DDS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:FAST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9102
Practice Address - Street 1:3311 E MURDOCK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3054
Practice Address - Country:US
Practice Address - Phone:316-689-9401
Practice Address - Fax:316-689-9798
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS49711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS022986OtherBCBS
KS12149505OtherMULTIPLANJ
T91573Medicare UPIN
KS12149505OtherMULTIPLANJ