Healthcare Provider Details

I. General information

NPI: 1043145451
Provider Name (Legal Business Name): CARLY LYNN CAMERON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 S BROADVIEW ST
CAPE GIRARDEAU MO
63703-5725
US

IV. Provider business mailing address

808 EAGLE DR
JACKSON MO
63755-3224
US

V. Phone/Fax

Practice location:
  • Phone: 573-332-0808
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2026027398
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: