Dental Board

Change of Name

Name Change

Profession:
License Number:
Previous Name:
First:
Middle:
Last:
Suffix:
New Name: (How it will appear on your license)
First:
Middle:
Last:
Suffix:
Phone Number:
Number of Duplicate Copies of License
(Please contact the Board to see if an additional fee may be required.)

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:
MISSOURI DENTAL BOARD

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