Organization
KELLY CLARK DDS PC
Active
Other names
Decatur Dental Care
Organization subpart
No
Provider details
NPI number
Authorized official
KELLY CLARK (OWNER/PRESIDENT)
(217) 423-2400
Entity
Organization
Contact information
Practice address
3737 US RT 36 E, DECATUR, IL 62521
(217) 423-2400
Mailing address
3737 US RT 36 E, DECATUR, IL 62521
(217) 423-2400
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
060009717
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1073693883
BLUE CROSS
IL
01
—
1700959020
BLUE CROSS
IL
01
—
1801059100
BLUE CROSS
IL
01
—
1942379458
BLUE CROSS
IL
Enumeration date
05/19/2009
Last updated
05/19/2009
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