Provider Demographics
NPI:1649769860
Name:MOORKAMP, STEPHEN VANCE (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:VANCE
Last Name:MOORKAMP
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4716
Mailing Address - Country:US
Mailing Address - Phone:573-578-6623
Mailing Address - Fax:
Practice Address - Street 1:912 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3350
Practice Address - Country:US
Practice Address - Phone:573-364-1345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170173711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice