Healthcare Provider Details

I. General information

NPI: 1992887467
Provider Name (Legal Business Name): STACY BECKER, DDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 11/13/2012
Certification Date:
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: 636-461-2255
  • 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: DR. STACY ELAINE BECKER OCHOA
Title or Position: OWNER/MEMBER
Credential: D.D.S.
Phone: 636-461-2255