Organization
DR CLARK K J PC
Active
Other names
Pana Family Dental
Organization subpart
No
Provider details
NPI number
Authorized official
KELLY CLARK DDS (PRESIDENT)
(217) 562-3330
Entity
Organization
Contact information
Practice address
128 S LOCUST ST, PANA, IL 62557-1430
(217) 562-3330
Mailing address
128 S LOCUST ST, PANA, IL 62557-1430
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
019026315
IL
Other
Enumeration date
10/17/2013
Last updated
10/17/2013
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