Mobile Dentistry Program Registration

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

FormDescription
3191Application for Mobile Dentistry Program Registration
3190Notice of Employee, Contractor, or Volunteer Change
2829Malpractice Suits or Claims Form (If applicable)
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​