Healthcare Provider Details

I. General information

NPI: 1598193153
Provider Name (Legal Business Name): DR CLARK K J PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 S LOCUST ST
PANA IL
62557
US

IV. Provider business mailing address

128 S LOCUST ST
PANA IL
62557
US

V. Phone/Fax

Practice location:
  • Phone: 217-562-3330
  • Fax:
Mailing address:
  • Phone: 217-562-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY CLARK
Title or Position: DOCTOR OWNER
Credential: DDS
Phone: 217-562-3330