Provider Demographics
NPI:1053783571
Name:REYNOLDS, ASIA (RDH)
Entity type:Individual
Prefix:MRS
First Name:ASIA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MISS
Other - First Name:ASIA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:8056 S KINGSTON AVE
Mailing Address - Street 2:APT. 1E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1293
Mailing Address - Country:US
Mailing Address - Phone:225-279-1040
Mailing Address - Fax:
Practice Address - Street 1:1502 E 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-2921
Practice Address - Country:US
Practice Address - Phone:773-496-5138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020012291124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist