Kyle Allen Clark, D.M.D.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

019030831 Issued in IL

Practice address

113 Cross Creek Blvd
Salem, IL 62881-1921

Phone

(618) 548-4480

NPI assigned

Jul 7, 2016

Last updated

Jul 7, 2016By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1467849600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1467849600000",
    "number": "1639521206",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "113 CROSS CREEK BLVD",
            "city": "SALEM",
            "state": "IL",
            "postal_code": "628811921",
            "telephone_number": "618-548-4480"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "113 CROSS CREEK BLVD",
            "city": "SALEM",
            "state": "IL",
            "postal_code": "628811921",
            "telephone_number": "618-548-4480"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "KYLE",
        "middle_name": "ALLEN",
        "credential": "D.M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-07-07",
        "last_updated": "2016-07-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "019030831",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lou B Bryant, PH.D
• Staci Lynn Burleyson, FNP-C
• Katie Jeannine Burmeister, D.C.
• Tracy Adele Caswell, APRN
• Quinn Kun Chen, DDS
• Danielle Nichole Cole, RBT
• Community Care Systems, Inc.
• Community Resource Center Inc
• Community Resource Center, Inc
• Cottages at Salem, Inc.

• General Practice Dentistry in Salem, IL
• Providers in Salem, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 7, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.