MEDICARE: KELLY CLARK DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	060009717	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1073693883	OTHER	IL	BLUE CROSS
2	1700959020	OTHER	IL	BLUE CROSS
3	1801059100	OTHER	IL	BLUE CROSS
4	1942379458	OTHER	IL	BLUE CROSS

General Provider Information

NPI Number	:	1982839056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY CLARK DDS PC

Provider Business Mailing Address
First Line	:	3737 E ROUTE 36
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62521
Country	:	US
Telephone Number	:	217-423-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	3737 E ROUTE 36
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62521
Country	:	US
Telephone Number	:	217-423-2400
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR OWNER
Name	:	DR. KELLY CLARK
Credential	:	DDS
Telephone Number	:	217-423-2400

Provider Enumeration Date	:	05/19/2009
Last Update Date	:	06/09/2026

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