Provider Demographics
NPI:1871752022
Name:FAST, JESSE DAVID (DDS)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:DAVID
Last Name:FAST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 DAKOTA AVE S
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-3318
Mailing Address - Country:US
Mailing Address - Phone:605-352-6999
Mailing Address - Fax:
Practice Address - Street 1:1010 DAKOTA AVE S
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-3318
Practice Address - Country:US
Practice Address - Phone:605-352-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD135122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist