KELLY CLARK DDS PC (NPI# 1982839056) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1982839056 |
| Entity Type | Organization |
| Organization Name | KELLY CLARK DDS PC |
| Other Organization Name | DECATUR DENTAL CARE |
| Practice Address |
3737 Us Rt 36 E Decatur IL 62521 |
| Practice Telephone | 2174232400 |
| Mailing Telephone | 2174232400 |
| Enumeration Date | 2009-05-19 |
| Last Update Date | 2009-05-19 |
| Authorized Official Name | KELLY CLARK (OWNER/PRESIDENT) |
| Authorized Official Telephone | 2174232400 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 1223G0001X |
Dentist Specialization: General Practice |
060009717 | IL | Dental Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| IL | BLUE CROSS | 1801059100 | 01 |
| IL | BLUE CROSS | 1700959020 | 01 |
| IL | BLUE CROSS | 1073693883 | 01 |
| IL | BLUE CROSS | 1942379458 | 01 |
| Other Name | Type Code |
|---|---|
| Decatur Dental Care | Doing Business As Name - Organization |
| Street Address |
3737 US RT 36 E |
| City | DECATUR |
| State | IL |
| Zip Code | 62521 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1053927988 | Caleb David Braasch | Pharmacist | 1818 South Airport Rd, Decatur, IL 62521 | 2020-09-16 |
| 1295390490 | Crossing Recovery Center | Substance Abuse Rehabilitation Facility | Crossing Recovery Center, 495 East Central Ave, Decatur, IL 62521 | 2019-05-03 |
| 1396300638 | Crossing Recovery Center | Substance Abuse Rehabilitation Facility | 495 E Central Ave, Decatur, IL 62521 | 2019-05-02 |
| 1679138911 | Crossing Recovery Center | Substance Abuse Rehabilitation Facility | 495 East Central Ave, Decatur, IL 62521 | 2019-05-02 |
| 1154848034 | Zack Shaw | Physical Therapist | 4855-57 East 36, Decatur, IL 62521 | 2017-08-23 |
| 1790032852 | Prashant Morolia | Family Medicine | 4775 E Maryland St, Decatur, IL 62521 | 2012-08-08 |
| 1003188913 | Evergreen Place Decatur, LLC | Assisted Living Facility | 4825 E Evergreen Court, Decatur, IL 62521 | 2012-02-08 |
| 1104133099 | Suzette Marie Shafer | Occupational Therapy Assistant | 1790 S. Fairview Ave., Decatur, IL 62521 | 2010-09-13 |
| 1467784090 | Community Health Improvement Center | Clinic/Center | 1221 East Condit Street, Decatur, IL 62521 | 2010-02-08 |
| 1275781593 | Deborah Deloney | Speech-Language Pathologist | Fairhaven Christian Home, 1790 South Fairview, Decatur, IL 62521 | 2008-08-28 |
| Find all providers in zip 62521 | ||||
| Taxonomy Code | 1223G0001X |
| Grouping | Dental Providers |
| Classification | Dentist |
| Specialization | General Practice |
| A general dentist is the primary dental care provider for patients of all ages. The general dentist is responsible for the diagnosis, treatment, management and overall coordination of services related to patients' oral health needs. |
| Notes: Source: Academy of General Dentistry |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1548870884 | Daniel Patrick Jurgens | Dentist | 2 N Country Club Rd Ste 2, Decatur, IL 62521-4174 | 2020-08-02 |
| 1134744576 | Dafna Lapidot | Dentist | 1074 Vistavia Cir, Decatur, GA 30033-3413 | 2020-06-11 |
| 1184140121 | Access Dental Care, LLC | Dentist | 1621 Wolverine Dr Se, Decatur, AL 35601-4933 | 2017-08-22 |
| 1154868917 | North Decatur Dentistry, PC | Dentist | 2570 Blackmon Drive, Suite 320, Decatur, GA 30033 | 2017-01-31 |
| 1245645084 | Mobile Dental Services of Alabama PC | Dentist | 3231 Fieldstone Dr Sw, Decatur, AL 35603-3173 | 2014-06-30 |
| 1619317518 | Jieun Jun | Dentist | 2450 Lawrenceville Hwy Ste 100, Decatur, GA 30033-3269 | 2013-06-25 |
| 1366794711 | Complete Dental Decatur LLC | Dentist | 1241 Point Mallard Parkway, Suite. 105, Decatur, AL 35601 | 2012-10-10 |
| 1891041570 | Decatur 2016 LLC | Dentist | 141 Epershing Rd, Decatur, IL 62526 | 2012-07-31 |
| 1467731679 | David Gatti Corless | Dentist | 301 W. Main St., Decatur, TX 76234 | 2011-08-05 |
| 1598092801 | Brandon Michael Piper | Dentist | 469 W Wood St, Decatur, IL 62522-3109 | 2009-11-06 |
| Find all providers in DECATUR | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.