Address Change

 

Name:  
License #:

Profession:  Please select one Dentist Hygienist Assistant       
Change in:  There is a change in my: Home address Work address Both

Home Address: City:
State:  Zip:

Home Phone:  
Home e-mail:

Wk Address: City:
State:  Zip:

Work Phone:    
Work e-mail:

All fields in red are required for submission.

Check this box when you have completed this form, then click "submit" to send the form. This box must be checked and by doing so you are certifying that the information given herein is true and correct to the best of your knowledge.

  

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In the Event of a Name Change

To change your name with the board, please mail the board a copy of the marriage certificate or marriage license, or divorce decree. The copy must be notarized as a true copy of the original document, and will not be returned.

As a reminder, the board does not issue new wallet cards or certificates upon a name change. Please keep in mind, it is appropriate that your wall certificate reflect the name under which your license or registration was originally issued. Your new name will appear on your renewal card if proof of name change is received prior to renewal of your licensure or registration. You can continue to use the certificate and wallet card that you currently have. If you would like to request a new wallet card with your new name, please submit a written request stating the reason for the duplicate card(s) along with a check or money order in the amount of $25 for each card requested.