=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942379458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY CLARK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 04/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3737 E RTE 36
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62521-5028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-423-2400
-----------------------------------------------------
Fax | 217-423-2460
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 BRENTWOOD DR
-----------------------------------------------------
City | MT ZION
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62549-1183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019026315
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------