Healthcare Provider Details

I. General information

NPI: 1720812175
Provider Name (Legal Business Name): ASHLEY BETH PRYOR RDH, PHDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E 12TH ST
FLORA IL
62839-2335
US

IV. Provider business mailing address

1359 N 1160 ST
VANDALIA IL
62471-4143
US

V. Phone/Fax

Practice location:
  • Phone: 618-403-5166
  • Fax:
Mailing address:
  • Phone: 217-690-5161
  • Fax: 217-235-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020011667
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: