Provider Demographics
NPI:1831464387
Name:SHELLY K. CLARK
Entity Type:Organization
Organization Name:SHELLY K. CLARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-291-0111
Mailing Address - Street 1:211 W BELT LINE RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-2066
Mailing Address - Country:US
Mailing Address - Phone:972-291-0111
Mailing Address - Fax:972-291-0315
Practice Address - Street 1:211 W BELT LINE RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2066
Practice Address - Country:US
Practice Address - Phone:972-291-0111
Practice Address - Fax:972-291-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX181131223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1891880076Medicaid