Healthcare Provider Details

I. General information

NPI: 1053783571
Provider Name (Legal Business Name): ASIA SMITH-VERNON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASIA SMITH-VERNON DMD

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-7171
  • Fax:
Mailing address:
  • Phone: 708-328-6935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019037238
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: