Failure to RENEW by DECEMBER 31, 2008 will result in the expiration of your license
LOUISIANA STATE BOARD OF DENTISTRY
365 CANAL STREET, SUITE 2680
NEW ORLEANS, LOUISIANA 70130
504-568-8574 office 504-568-8574 fax 1-877-467-4488 toll free
2009-2010 Application for DENTAL License Renewal
1. Please complete all questions and blank spaces on this renewal application, make any necessary corrections. Attach additional sheets if necessary.
2. Mail completed renewal application to the board address at the top of this form along with the $500.00 BIENNIAL DENTAL LICENSE RENEWAL
FEE, IF APPLICABLE, personal anesthesia permit renewal form and appropriate fee. Fee(s) should be submitted by check or money order payable to the
Louisiana State Board of Dentistry. All applications must be postmarked by the post office on or before December 31, 2008. IF RENEWAL APPLICATION IS
POSTMARKED AFTER DECEMBER 31, 2008 YOU ARE REQUIRED TO ADD A DELINQUENT FEE OF $250.00 or your application WILL BE RETURNED TO YOU AS
INCOMPLETE. THERE SHALL BE NO EXCEPTIONS.
Please check here if you do not wish to renew your license, sign below, and return this application to the board office at the above address.
If you wish to retire your license, please check here, sign and date the application and return this application to the board office at the above address.
OFFICE ADDRESS (1)
OFFICE ADDRESS (2)
OFFICE ADDRESS (3)
OFFICE ADDRESS (4)
IF YOU NEED ADDITIONAL SPACE, PLEASE USE THE BACK OF THIS FORM.
LIST ALL DENTAL HYGIENISTS EMPLOYED BY YOU. It is your duty to verify that the licenses of the dental hygienists employed by you are current. If not, you must
report this to the Louisiana State Board of Dentistry at the time this renewal application is submitted.
DO YOU DISPENSE OR ADMINI