Mississippi State Board of Dental Examiners

Saturday, April 19, 2014

Applications and Forms -- >
  Change of Information

The Mississippi State Board of Dental Examiners does not guarantee that changes submitted via e-mail will be received. Upon receiving changes, the Board will e-mail a confirmation notice to the Licensee's e-mail address, if listed, or to the e-mail address used by the Licensee for initial transmission of the changes. If the Licensee does not receive a confirmation notice within forty-eight (48) hours, contact the Board at telephone number 601-944-9622 or facsimile number 601-944-9624.

* The licensee must provide all information noted as "REQUIRED"; otherwise, complete only those sections requiring changes. ALL SECTIONS DO NOT NEED TO BE COMPLETED. The licensee may provide comments concerning these changes in the "COMMENTS" section.

* Dentists must submit separate forms for each satellite office or fictitious name to be changed.

* When all applicable changes have been provided, press the "SEND REQUEST" button located at the bottom of this form.

Required Information
E-Mail Addresses
Dentists MUST provide a minimum of one (1) currently valid e-mail address; however, the Board's database can accommodate a maximum of two (2) e-mail addresses for dentists. Dental hygienists and radiology permit holders MUST provide a minimum of one (1) currently valid e-mail address.

FAX Numbers
Telephone Numbers
Addresses
Please provide Address Line 1, Address Line 2, City, State, and ZIP

Dental Hygiene Employers or Employees
Dental hygienists should provide the full name(s) of any dental employer(s). The full name of the dentist(s), not the facility name(s), should be provided for dental employers. For non-dental employers, dental hygienists should provide the full name of the person or company, mailing address, telephone number, fax number, etc. Dentists should provide the full name(s) and license number(s) for any dental hygienist(s) providing dental hygiene services in your dental practice.

Radiology Permit Employers or Employees
Radiology permit holders should provide the full name(s) of any dental employer(s). The full name of the dentist(s), not the facility name(s), should be provided for dental employers. For non-dental employers, radiology permit holders should provide the full name of the person or company, mailing address, telephone number, fax number, etc. Dentists should provide the full name(s) and permit number(s) for all dental assistants who have radiology permits and expose radiographs in your dental practice.

Additional Information
Provide additional information or comments, if applicable, concerning the above changes.


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