Provider Demographics
NPI:1124227335
Name:CLARK, SALLY ANN KEESE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ANN KEESE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68503-1803
Mailing Address - Country:US
Mailing Address - Phone:402-476-1640
Mailing Address - Fax:402-476-1670
Practice Address - Street 1:1021 N 27TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68503-1803
Practice Address - Country:US
Practice Address - Phone:402-476-1640
Practice Address - Fax:402-476-1670
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD06301223G0001X
NE7190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice