Healthcare Provider Details

I. General information

NPI: 1750491833
Provider Name (Legal Business Name): STACY ELAINE BECKER D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 MAIN ST
IMPERIAL MO
63052-3861
US

IV. Provider business mailing address

1280 MAIN ST
IMPERIAL MO
63052-3861
US

V. Phone/Fax

Practice location:
  • Phone: 310-210-4967
  • Fax: 636-461-0401
Mailing address:
  • Phone: 636-461-2255
  • Fax: 636-461-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2002011129
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: