Licensing Forms

Dentists

Dental Licensure Application

Dentist Temporary Licensure for Charitable Purpose

Change of Address

Name Change Request

Duplicate Renewal License

Verification of Licensure Request

Designation of Records

Board Scores

Wall License Replacement

Clinical Affidavit

N2O & Level 1 Anesthesia Affidavit 

Level 2-4 Anesthesia Affidavit

Faculty Renewal Employer Affidavit

Retirement Request Form

Hygienists

Dental Hygiene Licensure Application

Change of Address

Name Change Request

Duplicate Renewal License

Name Change Request

Duplicate Renewal License

Verification of Licensure or Registration

Board Scores

Wall License Replacement

Clinical Affidavit

Faculty Renewal Employer Affidavit

Retirement Request Form

Dental Assistants

Change of Address

Name Change Request

Verification of Certificate or Registration

Duplicate Renewal License

Retirement Request Form

Dental Laboratories

Change of Address

Change the Certified Dental Technician of Record

Closure Notification

Mobile Facilities

Change of Address – 2021

Duplicate Registration Certificate