Home Dentist Dentist Text field Thank you for choosing to pay for your service with the Board’s online payment option. This form is for paying for your Dentist licensing fees. Fields marked with an asterisk are required and must be completed prior to clicking Pay Now. A $2.00 Convenience Fee will automatically be added to your total. Customer Information First Name Last Name License Number # Email @ Phone Number # Address Address City/Town State/Province ArizonaAlabamaAlaskaAmerican 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 Products Options Licensure by Credential Fee - $2,000 Universal Credential Fee - $2,000 Prorated Initial License Fee - $110 Triennial Renewal Fee - $510 Triennial Renewal Fee for Retired / Disabled Status - $15 Additional Office Triennial Certificate - $25 Late Renewal Fee - $100 Anesthesia and Sedation Permit (Initial License) - $300 Anesthesia and Sedation Permit (Renewal) - $300 Anesthesia and Sedation Permit (each additional location) - $25 Jurisprudence Examination - Nonrefundable - $300 Additional Office Triennial Certificate Quantity ($25 each) - Select -12345 Anesthesia and Sedation Permit Quantity ($25 each) - Select -12345 Payment Detail Preview Leave this field blank