Mobile Dentistry Program Registration

Pursuant to 2017 Wisconsin Act 278, beginning August 1, 2018, prior to submitting an application for a credential, an individual may apply to the Department for a determination of whether the individual would be disqualified from obtaining the credential due to his or her conviction record.  To apply for a predetermination, please fill out Form #3085 and submit all required documentation specified on the form.  Pursuant to Wis. Stat. § 111.335(4)(e), the offenses or kinds of offenses that may result in a refusal, bar, or termination of licensure are published under Additional Resources on the left side of this page.


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

FormDescription
3191Application for Mobile Dentistry Program Registration
​3217​Application for Fee Reduction (This form must accompany the application for the credential)
3190Notice of Employee, Contractor, or Volunteer Change
2829Malpractice Suits or Claims Form (If applicable)
​3085​Application for Predetermination
2252​Convictions and Pending Charges
3071​Fax Payment Form

  Renewal Information

Requirements

  • FEE (See Renewal Dates and Fees)

Renewal Methods

  • Online Log In: License Renewal Online
  • Request a Paper Renewal Form: (888) 506‑4239 or (608) 261‑4460 for the Madison area
FormDescription

RDAF

Renewal Dates and Fees

​3205Mobile Dentistry Program Renewal Addendum​