Provider Demographics
NPI:1982839056
Name:KELLY CLARK DDS PC
Entity Type:Organization
Organization Name:KELLY CLARK DDS PC
Other - Org Name:DECATUR DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-423-2400
Mailing Address - Street 1:3737 US RT 36 E
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521
Mailing Address - Country:US
Mailing Address - Phone:217-423-2400
Mailing Address - Fax:
Practice Address - Street 1:3737 US RT 36 E
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-423-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0600097171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1073693883OtherBLUE CROSS
IL1700959020OtherBLUE CROSS
IL1801059100OtherBLUE CROSS
IL1942379458OtherBLUE CROSS