License Information
Fee Reduction
Pursuant to 2017 Wisconsin Act 319, beginning August 1, 2018, an applicant for an initial credential may apply for a reduction of the initial credential fee that is equal to 10% of the initial fee. Qualification is based on the federal adjusted gross income being at or below 180% of the federal poverty guideline prescribed for the applicant's family household size by the United States Department of Health and Human Services. To determine eligibility please visit the United States Department of Health and Human Services website at https://aspe.hhs.gov/poverty-guidelines, prior to submitting Form 3217.
Per
Wis. Stat. § 440.08 (2), the required renewal date for the Mobile Dentistry Program Registration is 10/01/odd years. Should you receive your initial credential in the months leading up to this date, you are still required to renew your license by the statutorily defined date.
An applicant for registration to own or operate a Mobile Dentistry Program shall submit all of the following:
- Application for Mobile Dentistry Program Registration
- A list of all employees, contractors, or volunteers who are providing dental or dental hygiene care in Wisconsin, including the Wisconsin license number for each person providing dental care.
A person who wishes to own or operate more than one Mobile Dentistry Program in this state shall apply for a separate registration for each Mobile Dentistry Program.
Application for Licensure
| Form | Description |
|---|
|
3191 | Application for Mobile Dentistry Program Registration |
| 3217 | Application for Fee Reduction (This form must accompany the application for the credential) |
|
3190 | Notice of Employee, Contractor, or Volunteer Change |
|
2829 | Malpractice Suits or Claims Form (If applicable) |
|
3085 | Application for Predetermination (Optional-Submit ONLY if you have been convicted of any felony, misdemeanor, or other violations of federal or state law in this state or any other and you desire a review of your conviction record before applying for a credential.)
|
|
2252 | Convictions and Pending Charges |
|
3071 | Fax Payment Form |