Address Change Form

Address Change Form

Pursuant to ORS 679.120(4) and 680.075(4) all licensed dentists and dental hygienists must notify the board within 30 days of any change of address.

This form is intended for licensed DENTISTS and DENTAL HYGIENIST who hold an Oregon License as well as current Applicants for licensure.

We CANNOT process this information via phone so please do not call the Board office. If you are unable to submit this form online you can print it out and either mail or fax the information.

Please keep in mind that the Board must have at least on physical address on file for it's licensees at all times. If you wish to use a PO Box address, update the physical address on file in either the home or work fields, then use the 'Other Mailing Address of Record' for the PO Box address. Do not enter PO Box information in the Home address field.