Provider Demographics
NPI:1124699657
Name:KRISHER, JACOB RYAN (DMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:KRISHER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 W CANDLETREE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8509
Mailing Address - Country:US
Mailing Address - Phone:309-692-6206
Mailing Address - Fax:
Practice Address - Street 1:3316 N AVALON PL
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1472
Practice Address - Country:US
Practice Address - Phone:309-335-0531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190332841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice