MEDICARE: DR. STACY ELAINE BECKER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2002011129	MO

General Provider Information

NPI Number	:	1750491833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY ELAINE BECKER D.D.S.

Provider Business Mailing Address
First Line	:	1280 MAIN ST
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052-3861
Country	:	US
Telephone Number	:	636-461-2255
Fax Number	:	636-461-0401

Provider Business Practice Location Address
First Line	:	1280 MAIN ST
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052-3861
Country	:	US
Telephone Number	:	310-210-4967
Fax Number	:	636-461-0401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	06/27/2024

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