Provider Demographics
NPI:1942379458
Name:CLARK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3737 E RTE 36
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5028
Practice Address - Country:US
Practice Address - Phone:217-423-2400
Practice Address - Fax:217-423-2460
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190263151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice