Change of Name


Important:
In order to update your name, you must submit supporting documentation such as a copy of your marriage license or divorce decree.

PLEASE MAIL TO:
ISSOURI DENTAL BOARD

P.O. Box 1367, Jefferson City, Missouri 65102-1367
Phone: (573) 751-0040
Fax: (573) 751-8216
Email: dental@pr.mo.gov

Licensee Information
*
*
*

Previous Name
*
*

New Name:
How it will appear on your license
*
*

Additional information