Provider Demographics
NPI:1639521206
Name:CLARK, KYLE ALLEN (DMD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ALLEN
Last Name:CLARK
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 1:113 CROSS CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1921
Mailing Address - Country:US
Mailing Address - Phone:618-548-4480
Mailing Address - Fax:
Practice Address - Street 1:113 CROSS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1921
Practice Address - Country:US
Practice Address - Phone:618-548-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190308311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice