Home Dentist Renewal Application Dentist Renewal Application Current Dentist Information Conduct Continuing Education Citizenship Status Signature Complete Pursuant to A.R.S. § 32-1236 “…a license expires thirty (30) days after the licensee’s birth month every third year. On or before the last day of the licensee’s birth month every third year, [a licensee] shall submit…a complete renewal application and pay a license renewal fee” to prevent expiration. To renew your license, please complete the following application and submit the prescribed renewal fee. Applications postmarked after the expiration date are required to pay the late fee penalty of $100. The licensee must also affirm that they attended at least the minimum hours of recognized continuing dental education within their respective license type. Licensee Identification Last Name? First Name? Middle Name or Initial? Current License Number? # Email Email? @ Confirm email @ You will receive a confirmation email at the email address entered. You will need to confirm your email and then pay to complete the application process. Failure to do so will result in having to resubmit the application. Pursuant to A.R.S. § 32-1262(H), if you legally changed your name and desire that your renewed license be in the new name, please complete the online Name Change Form. Address of Record Pursuant to A.R.S. § 32-1236(I) you must notify the Board of any change to your primary mailing address, in writing, and within 10 days of the change. ADDRESS OF RECORD – select one: Residential Address Practice Address Mailing Address Opt Out This is the address that will be shared with the public and to where all Board correspondence will be mailed. Pursuant to A.R.S. § 32-3226, if you select your residential address as your address of record, but wish that it not be made available for public disclosure and only used to receive Board correspondence, you may opt out of the disclosure by initialing here: Initial here to opt out Initial Address of Record Name of Business Entity/Practice Email @ Phone Number # Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Primary Place of Practice Not Applicable Name of Business Entity/Practice Email @ Primary Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Secondary Place of Practice You will be charged a fixed fee of $25 for each additional practice address. Not Applicable Name of Business Entity/Practice Email @ Secondary Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Additional Places of Practice If you have additional places of practice please attach the document here Additional Places of Practice Upload One file only.10 MB limit.Allowed types: pdf. Renewal Options Options Triennial Renewal Fee - $510 Triennial Renewal Fee for Retired / Disabled Status - $15 Additional Office Triennial Certificate - $25 Late Renewal Fee - $100 Additional Office Triennial Certificate Quantity ($25 each) # - Select -12345678910 Payment Detail Next > Leave this field blank