Provider Demographics
NPI:1821684929
Name:SHELLY K. CLARK, DENTISTRY FOR CHILDREN
Entity Type:Organization
Organization Name:SHELLY K. CLARK, DENTISTRY FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-291-4281
Mailing Address - Street 1:4450 E HIGHWAY 287
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-5576
Mailing Address - Country:US
Mailing Address - Phone:972-723-0111
Mailing Address - Fax:
Practice Address - Street 1:4450 E HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-5576
Practice Address - Country:US
Practice Address - Phone:972-723-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHELLY K. CLARK, DENTISTRY FOR CHILDREN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210909202Medicaid