License Information
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 |
| 3190 | Notice of Employee, Contractor, or Volunteer Change |
| 2829 | Malpractice Suits or Claims Form (If applicable) |
| 2252 | Convictions and Pending Charges |
| 3071 | Fax Payment Form |
