Home Dental Therapists Dental Therapists 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 Dental Therapy 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 Dental Therapy Credential - $1,500 Dental Therapy Universal - $1,500 Dental Therapy Prorated Initial License - $80 Dental Therapy Renewal - $375 Dental Therapy Triennial Renewal Fee for Retired/Disabled Status - $15 Late Renewal Fee - $100 Dental Therapy Jurisprudence - $200 Payment Detail Preview Leave this field blank