OH Dental Board Address Change Form 2015-2025 free printable template

Do Not Write In This Space Ohio State Dental Board 77 S High St 17th Fl Columbus OH 43215-6135 Phone 614. 466. 2580 Fax 614. 752. 8995 www. dental*ohio. gov OH Lic/Cert/Reg Name first middle last ADDRESS CHANGE FORM By statute within 10 days of relocation dentists must provide the Board with the new practice location address. residence address and/or employer. New Address Daytime Phone Street Fax/Alternate Phone City Email address State Zip County New Employer Employer Phone City State Zip...

How to fill out ohio change address form

How to fill out OH Dental Board Address Change Form

1. Obtain the OH Dental Board Address Change Form from the official website or by contacting the board directly.
2. Fill in your personal information at the top of the form, including your name, license number, and current address.
3. Indicate your new address in the designated section of the form.
4. Provide any additional requested information, such as phone number or email address if applicable.
5. Review the form for accuracy to ensure all information is correctly filled out.
6. Sign and date the form at the bottom to verify the information provided.
7. Submit the completed form to the OH Dental Board via the specified submission method, such as mail or email.

Who needs OH Dental Board Address Change Form?

1. Any licensed dental professional in Ohio who has changed their residential or practice address needs to fill out the OH Dental Board Address Change Form.
2. Dental hygienists, dentists, and any other dental-related license holders must complete the form to ensure their records are up-to-date.

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What is OH Dental Board Address Change Form?

The OH Dental Board Address Change Form is a document used to notify the Ohio Dental Board of any changes to a dentist's or dental hygienist's address.

Who is required to file OH Dental Board Address Change Form?

All licensed dentists and dental hygienists in Ohio are required to file the OH Dental Board Address Change Form when they change their mailing or practice addresses.

How to fill out OH Dental Board Address Change Form?

To fill out the OH Dental Board Address Change Form, individuals must provide their current contact information, the new address, and their license number, and then submit the completed form to the Ohio Dental Board.

What is the purpose of OH Dental Board Address Change Form?

The purpose of the OH Dental Board Address Change Form is to ensure that the Ohio Dental Board has accurate contact information for licensed professionals, which is essential for communication and regulatory purposes.

What information must be reported on OH Dental Board Address Change Form?

The information that must be reported on the OH Dental Board Address Change Form includes the licensee's name, license number, old address, new address, and contact information.