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General NPI Number Information
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NPI Number | 1669567772
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Entity Type | Organization
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Legal Business Name | SHELLY K. CLARK D.D.S., P.A.
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 211 W BELT LINE RD SOUTH SUITE
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City | CEDAR HILL
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State | TX
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Zip | 75104-2066
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Country | US
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Telephone | 972-291-0111
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Fax |
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Provider Business Mailing Address
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Address Line | 211 W BELT LINE RD SOUTH SUITE
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City | CEDAR HILL
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State | TX
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Zip | 75104-2066
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Country | US
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Telephone | 972-291-0111
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/ CEO
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Name | DR. SHELLY K. CLARK
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Credential | D.D.S.
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Telephone | 972-291-0111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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