Individual
KELLY CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3737 E RTE 36, DECATUR, IL 62521-5028
(217) 423-2400
(217) 423-2460
Mailing address
1710 BRENTWOOD DR, MT ZION, IL 62549-1183
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019026315
IL
Other
Enumeration date
11/07/2006
Last updated
04/21/2010
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