DCI | Missouri Division of Professional Registration

General Inquiries

Dental Board
3605 Missouri Boulevard
P.O. Box 1367
Jefferson City, MO 65102-1367
573.751.0040 Telephone
573.751.8216 Fax
800.735.2966 TTY
800.735.2466 Voice Relay
dental@pr.mo.gov
https://pr.mo.gov/dental.asp

Change of Address

Name as it appears on the certificate

Last Name: *

First Name: *

Middle Initial:

Profession: *

License Number: *

Current Phone Number: _{(Please include area code)}
*

Current Email: *

Current Fax:

Please indicate whether you want information sent to your home or business address.

HomeBusiness

Old Home Address

Street (line 1):

Street (line 2):

City:

State:

Zip Code:

New Home Address

Street (line 1):

Street (line 2):

City:

State:

Zip Code:

Old Business Address

Business Name:

Street (line 1):

Street (line 2):

City:

State:

Zip Code:

New Business Address

Business Name:

Street (line 1):

Street (line 2):

City:

State:

Zip Code:

Change in permit and/or site certificate?Do you also have either an ECS, PCS or DSGA permit and/or site certificate that the above address change will effect?*

YesNo

If so, please indicate the appropriate permit and/or site certificate numbers below. (Please note that if you have changed practice locations, you will need to apply for a new site certificate.)

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General Inquiries

Dental Board

Change of Address