Provider Demographics
NPI:1740358753
Name:BAST, KELLY CATHERINE (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CATHERINE
Last Name:BAST
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 1:3112 AIRPORT WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4768
Mailing Address - Country:US
Mailing Address - Phone:907-452-1250
Mailing Address - Fax:
Practice Address - Street 1:3112 AIRPORT WAY STE 1
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4768
Practice Address - Country:US
Practice Address - Phone:907-452-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11881223S0112X, 122300000X, 1223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223X2210XDental ProvidersDentistOrofacial Pain
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1188OtherSTATE OF ALASKA LIC.