Provider Demographics
NPI:1588929848
Name:FAST, PATRICIA JORDAN (DMD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:JORDAN
Last Name:FAST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:PATRICIA
Other - Middle Name:LOUISE
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:904 MOHAWK DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5705
Mailing Address - Country:US
Mailing Address - Phone:843-269-4266
Mailing Address - Fax:
Practice Address - Street 1:1507 HERITAGE LN
Practice Address - Street 2:SUITE A
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-3141
Practice Address - Country:US
Practice Address - Phone:843-665-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC80681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice