Name and Address Changes - Licensed Dentists

Every dentist is required to register his/ her place(s) of practice with the Board on a form prescribed by the Board. B&P §§ 1650, 1651 Every dentist licensed in this state must also notify the Board if he/she has no place of practice. Any dentist who changes his/her place of practice must register with the Board within one month after the change.

Address Change

In the event any licensee fails to notify the Board of a change of address within one month, the board may not renew his/her license until the penalty is paid. The penalty for late registration of change of place of practice is $50.00.

All places of practice must be registered with the Board. An additional office permit is required if a licensee has proprietary interest of any nature, or any right to participate in the management or control of more than one place of practice. B&P §1658.

Fictitious Name Permits and Additional Office Permits are address-specific. A change in the address of these permits requires a new application.

• Change of Address Form

Name Change

A legal name change must be reported within 10 days. You must submit photocopies or electronic copies of the following two required documents with your Notification of Name Change form:

1. A current government issued photographic identification (e.g. driver license, alien registration, passport, etc.) AND
2. One of the following additional legal documents as proof of name change

• Certified Court Order
• Marriage Certificate
• Dissolution of Marriage (Divorce)
• Notification of Name Change

There is no fee for a name change unless a replacement pocket or wall license is requested. Once the name is changed, the next pocket license will automatically be issued be in the new name.

Fees

The fee to replace a pocket license is $50, unless the name change coincides with license renewal.

The fee to replace a wall license is $50 and requires the return of the original wall license.