Virginia Board of Dentistry

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9960 Mayland Drive, Suite 300

Henrico, Virginia 23233


(804) 367-4538 (Tel)
(804) 698-4266 (eFax)
[email protected]
www.dhp.virginia.gov/dentistry

APPLICATION INSTRUCTIONS FOR A DENTAL LICENSE

There are two pathways for licensure in Virginia, licensure by examination or licensure by credentials. Read through the
application instructions carefully before deciding which pathway to pursue. A completed application shall include the following
unless otherwise stated below. An incomplete application and/or fee will delay the processing of your application. Incomplete
applications remain active for one year from the date of receipt. After one year from date of receipt, you would need to reapply
for Virginia licensure. Documents submitted with an application are the property of the Board of Dentistry and cannot be
returned. If you need to receive approval to sit for a clinical exam, then you would need to use the pathway for licensure by
examination application and select a testing agency in order to be approved.

You may view the status of the checklist items for your application by visiting the Online Applications website, creating an
online account, log in with your User ID and Password, and clicking on the "View Checklist" link in the Pending Licenses
section. Using the View Checklist feature will allow you to review which application items have been completed and which
are still outstanding.

1. Application: Please be sure that all information and questions are completed on the application.

2. Application Fee: The fee for a dental license by examination is $400 and the fee for a dental license by
credentials is $500, which must be paid online using a VISA, MasterCard or Discover. The fee can be used
for one year from date of receipt. Pursuant to 18VAC60-21-40(G), all fees are non-refundable. Your
application will not be submitted to the Board of Dentistry for review until you have submitted your payment.

3. Form A Certification of Graduation (For Post-Doctoral Specialty Programs Only): Original certification
of graduation by each post-doctoral specialty dental school which granted you a dental degree or certificate
from a dental program accredited by the Commission on Dental Accreditation of the American Dental
Association (CODA) or the Commission on Dental Accreditation of Canada (CDAC), at least a 12-month post-
doctoral advanced general dentistry program or a post-doctoral dental education program of at least 24
months that includes a clinical component.
Applicants must submit a Form A for each degree and/or certificate earned from a post-doctoral specialty
dental program accredited by CODA or CDAC. The school may use this form or its own form to meet this
requirement.
The certification form must bear the school’s seal or be on letterhead bearing the school’s seal and must
include the program’s CODA/CDAC accreditation status at the time you completed the program. This
information is only accepted from programs accredited by CODA or CDAC.
Documentation from foreign schools is not required and will not be considered.
(May be mailed to the Board or emailed to the Board directly from the school/agency official representative.
Faxed copies are not acceptable.)
Note: This form only needs to be completed if you completed a post-doctoral specialty program.

4. Official Transcript: Final original transcript bearing SEAL, date degree received (conferred date) and
registrar’s signature. Copies of transcripts, certificates and diplomas are not acceptable. If you completed a
post-doctoral program at a hospital which does not maintain transcripts, a letter that addresses the coursework
and clinical training that you completed, signed by the Program Director, is required.
(May be mailed to the Board or emailed to the Board directly from the school, e-scrip, or parchment services
provider. An official transcript –must be on original official school paper (sealed) or an online version that
Board staff must download from the school, e-scrip or parchment services website.)

Dentist Online Application Instructions Revised June 2022 1


5. Form C License Verification (must print form): Original licensure status and certification from every
jurisdiction in which you currently hold or have ever held a license/registration/certification to practice as
adentist or as another health care professional. Copies of permits are not accepted. Certifications cannot be
older than 6 months from date prepared.
(May be mailed to the Board or emailed to the Board directly from the issuing state official state representative.
If the issuing state/jurisdiction (agency) does not provide an original document then the applicant must
provide/submit the issuing agency statement as to why the issuing agency does not provide verification and
submit a copy of the electronic version from the issuing agency website to the Board.)

6. Clinical Scores: An original and one (score cards cannot be combined) detailed score card or report from a
Board Approved testing agency documenting passage of a clinical competency examination; meaning a formal
test of knowledge and competence in the evaluation, diagnosis, and treatment of dental conditions and the
prevention of dental diseases which includes live patient and/or manikin based testing methods to demonstrate
the skills needed to safely provide care and treatment of patients, is required.
Candidate’s score cards are not acceptable. All score cards or reports must be requested by the
applicant. (Canadian exams are not accepted.) Certificates are not accepted. (May be mailed to the Board
or you must contact the testing agency to request that your test results be made available to the Virginia Board
of Dentistry via online access portal.)
See Guidance Document 60-25 Policy On Dental Clinical Competency Examination Requirements For
Licensure, for both application by examination and credentialing for complete details. The Board does not
accept exams that do compensatory scoring, it is the applicant’s responsibility to check with their testing
agency about compensatory scoring.

If applying by examination: Applicants who successfully completed a clinical competency examination five
or more years prior to the date of receipt of their applications for licensure by this board would be required to
provide one of the three documentation options Note: It is the applicant’s responsibility to prove clinical
competency:
1. retake a board-approved examination (original copy of exam scores)
2. take board-approved clinical continuing education as evidence of continuing competence that meets the
requirements of 18VAC60-21-250 (copy of completed coursework certificate or transcript that shows the
percentage of clinical hands-on training)
3. submit documentation that you have maintained clinical, ethical, and legal practice in another jurisdiction
of the United States or in federal civil or military service for 48 of the past 60 months immediately prior to
submission of an application for licensure. (May use our employment of verification form on page 8 to
document employment.)
Approval to take a regional examination will only be granted to applicants who are otherwise eligible for an
unrestricted license as documented in a completed application. Approval will not be granted to applicants
who do not hold a diploma or certificate from a dental program accredited by CODA or CDAC, as required by
§54.1-2709.B (ii) of the Code of Virginia and by 18VAC60-21-200 of the Regulations Governing the Practice
of Dentistry. You would need to satisfy all of the licensure requirements other than having completed an
acceptable clinical exam therefore you would indicate on the application the exam-testing agency you would
like to be approve to sit/take a clinical exam.)
If applying by credentials: See the additional requirements in numbers 12, 13, and 14 before selecting
this pathway.

7. NBDE: An original grade card indicating passage of all parts of the National Board Dental Examination
issued by the Joint Commission on National Dental Examinations is required. Copies of grade cards are not
accepted. (You must contact the testing agency to request that your test results be made available to the
Virginia Board of Dentistry via their online access portal.)

8. NPDB: An original current report, not older than 6 months from date prepared, must be obtained by Self
Query from the National Practitioner Data Bank (NPDB), which may be requested through their website at
www.npdb.hrsa.gov. There is a fee for this report. This report from NPDB is required from all applicants,
without exception (Regulation 18VAC60-21-190.3).

Dentist Online Application Instructions Revised June 2022 2


9. Please be aware that your electronic signature authorizes the release of confidential information, affirms that
your application is complete and correct, and attests that you have read, understand, and will remain current
with the laws and regulations governing the practice of dentistry in Virginia. Review the laws and regulations
via the “Laws and Regulations” tab at www.dhp.virginia.gov/dentistry.

10. Name Change: Documentation must be provided to show each name change, if your name has ever been
changed since graduation from a CODA or CDAC accredited program or were licensed in other jurisdictions
or other than what is listed on your application. Photocopies of marriage licenses or court orders are
accepted. (May be mail/fax/email to the Board.)

11. Address of Record and Publically Disclosable Address: Consistent with Virginia law §54.1.2400.02 and
the mission of the Department of Health Professions, addresses of licensees are made available to the public.
Normally, the Address of Record is the publically disclosable address. If you do not want your Address of
Record to be made public, state law allows you to provide a second, publically disclosable address. Typically,
this other address is the work or practice address. If you would like for your Address of Record to be made
available to the public, complete both sections with the same address.

Additional requirements for licensure by credentials which is the pathway to licensure for an applicant who holds a
license in another state, who passed a clinical competency exam referenced for acceptance for licensure by examination
in number 6 above, and who has recently practiced dentistry for at least 5 years. The applicant is additionally required to:

12. Form B Chronology (complete online or print form): List ALL personal and professional activities, to
include all time periods of employment and unemployment, since receiving your doctoral degree or post-
doctoral advanced certification. (Resumes and curriculum vitae are not accepted as substitutes for completing
the chronological listing on Form B and will not be considered.) (Form B may be email/fax/mail to the Board)

13. Hold a current, unrestricted license to practice dentistry in another jurisdiction in the United States which was
obtained by successfully passing a clinical competency examination comparable to the exam required by the
Commonwealth of Virginia and are certified to be in good standing by each jurisdiction in which you currently
hold or have held a license.
14. Provide the Number of Hours of clinical practice for each dental position held within the six-year period prior
to submitting an application. Hours must be reported per calendar year. To qualify for licensure by credentials
the applicant must have practiced a minimum of 600 hours in each of five calendar years during the six years
immediately preceding your application. The Board counts back six years from the date of receipt of an
application.

For example, the six year period immediately preceding an application received on June 9, 2022 began on
June 10, 2016. The six calendar years for this example application are:

First year: June 10, 2016 to June 9, 2017;


Second year: June 10, 2017 to June 9, 2018;
Third year: June 10, 2018 to June 9, 2019;
Fourth year: June 10, 2019 to June 9, 2020;
Fifth year: June 10, 2020 to June 9, 2021, and
Sixth year: June 10, 2021 to June 9, 2022.

Additional requirements for Oral and Maxillofacial Surgeons (Code §54.2709.1 and 2)
Prior to practicing as an oral and maxillofacial surgeon, you are required to register with the Board of Dentistry (see
Regulation 18VAC60-21-310). You are also required to obtain certification before performing certain cosmetic procedures
(see Regulation 18VAC60-21-350). The applications for registration and certification are available at
www.dhp.virginia.gov/dentistry or you may request the forms by calling the Board office at (804) 367-4538. Once you are
registered with the Board, you will receive instructions for completing a profile of information about your practice for the
public.

NOTES:
 Completed applications cannot be accessed or edited once they have been submitted.
 If your Virginia License is not issued within 6 months of the date of the NPDB (National Practitioner Databank) Self Query
Report and certification of state licensure, you will be asked to submit a current NPDB Self Query Report and current state
licensure certification before your application can be reviewed.

Dentist Online Application Instructions Revised June 2022 3


 DEA Registration: Applicants must have a dental license prior to applying for a DEA License. Requests for an application in
Virginia should be made to the following: Drug Enforcement Administration, Attn: Registration Section/ODR, P.O. Box 2639,
Springfield, VA 22152-2639; 1-800-882-9539; www.deadiversion.usdoj.gov

 To receive notice that your supporting documents have been delivered to the board, it is suggested that the documents be
mailed by Fed-Ex or UPS with “Delivery Confirmation”. Mail sent by USPS is sent to a separate state processing facility
that is offsite and therefore mail can be delayed. Note: if you send something certified by USPS it only verifies that
it got to the processing facility and not the Board. 

 The Board does not have reciprocity with any other jurisdiction and cannot grant requests for exceptions to the policies, laws,
or regulation nor predetermine acceptance of any documentation prior to the receipt of a complete application. 
 Applicant will be notified of missing application items within approximately 15 business days of receipt of an application. Once
your application is deem complete, allow 30 business days processing time.

Related contact information:

SRTA CITA CRDTS*


4698 Honeygrove Road, Suite 2 1518 Elm Street, Suite A 1725 SW Gage Blvd
Virginia Beach, VA 23455 Sanford, NC 27330 Topeka, KS 66604
757-318-9082 919-460-7750 785-273-0380
757-318-9085 FAX 919-460-7715 FAX 785-273-5015 FAX
www.srta.org www.citaexam.com www.crdts.org

WREB* NERB/CDCA Approved Programs


23460 N. 19th Ave, Suite 210 1304 Concourse Dr, Suite 100 ADA (American Dental Association)
Phoenix, AZ 85027 Linthicum, MD 21090 CODA (Commission on Dental Accreditation)
623-209-5400 301-563-3300 211 East Chicago Avenue
602-371-8131 FAX 301-563-3307 FAX Chicago, IL 60611-2678
www.wreb.org www.cdcaexams.org 1-800-621-8099 or 312-440-4653
https://www.ada.org/en/coda

National Practitioner Data Bank National Board Scores


P.O. P.O. Box 10832 Joint Commission on National Dental Examinations
Chantilly, VA 20153 211 East Chicago Avenue
1-800-767-6732 Chicago, IL 60611-2678
www.npdb.hrsa.gov 1-800-232-1694
www.ada.org/jcnde/examinations
Effective November 30, 2016, the National Board Dental Examination (NBDE)
result reports will no longer be sent via mail.

*The Board does not accept exams that


do compensatory scoring, it is the
applicant’s responsibility to check with
their testing agency about compensatory
scoring.

VA Board of Dentistry Mailing/Delivery Address:


Virginia Board of Dentistry
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233

Dentist Online Application Instructions Revised June 2022 4


9960 Mayland Drive, Suite 300
Henrico, Virginia 23233
(804) 367-4538 (Tel)
(804) 698-4266 (eFax)
[email protected]
www.dhp.virginia.gov/dentistry

FORM A
CERTIFICATION OF DENTAL SCHOOL
Post-Doctoral Specialty Programs ONLY

Applicant: Enter only your name and graduation date below, then send this form to the Dean or Director of each Post-
Doctoral Dental School or Program which granted you a degree or certificate.
APPLICANT GRADUATION DATE:
DEAN/PROGRAM DIRECTOR: Please provide certification that the applicant named above received a dental degree
or certificate from your program and certification that the program completed was accredited by the Commission
on Dental Accreditation of the ADA (CODA) or the Commission on Dental Accreditation of Canada (CDAC) at the
time the applicant completed the program. The certification may be provided by completing this form or by
providing a letter with all the information requested on this form. Either document must bear the school’s seal.
Certifications made prior to the applicant’s graduation cannot be accepted.
NAME OF SCHOOL:

NAME OF PROGRAM:
PROGRAM’S CODA/CDAC ACCREDITATION STATUS ON THE DATE THE DEGREE OR CERTIFICATION WAS
GRANTED:

A1: Approval (without reporting requirements) [ ]


A2: Approval (with reporting requirements) [ ]
IA: Initial accreditation [ ]
DIS: Accreditation voluntarily discontinued [ ]
WDRN: Accreditation withdrawn [ ]
X: Intent to withdraw accreditation [ ]
T: Program is in Teach-Out by institution [ ]
NE: Required period of non-enrollment [ ]
DEGREE or CERTIFICATION GRANTED:
DATE DEGREE or CERTIFICATION GRANTED: / /
Month Day Year
By affixing my signature below, I certify that the applicant named above is a graduate and a holder of a diploma or a
certificate from a CODA/CDAC accredited dental program.

Signature

SEAL Print Name

Title

Date

DEAN/REGISTRAR: Please provide the applicant an original final transcript of this alumni record, to include courses, grades, degree
or certificate received, and date the degree or certificate was conferred, which bears the certified signature of the registrar and has the
college seal affixed.

Dentist Online Application Instructions Revised June 2022 5


9960 Mayland Drive, Suite 300
Henrico, Virginia 23233
(804) 367-4538 (Tel)
(804) 698-4266 (eFax)
[email protected]
www.dhp.virginia.gov/dentistry

FORM B
CHRONOLOGY
ONLY APPLICABLE TO LICENSURE BY CREDENTIALS (DO NOT COMPLETE FOR LICENSURE BY
EXAMINATION)

APPLICANT NAME:_______________________________________________________________________________

Credential applicants must provide a complete chronological, personal and professional history of all activities you have engaged in
since receiving your degree or certification, including teaching positions, all periods of non-professional activity or employment,
volunteer work and all periods of unemployment. Curriculum vitae and resumes are not accepted as substitutes for completing
the chronological listing and will not be considered.

Only applicants for dental licensure by credentials are required to provide the Number of Hours of Clinical Practice. You
must report the number of hours you were engaged in clinical practice for each dental position you held within the six year
period prior to submitting this application. Report multiple year positions as hours per calendar year, i.e. 600 hours in 2016
or 1000 hours each year for 2016 - 2022.

Form B may be photocopied if additional space is needed.

Number of
FROM TO POSITION/ACTIVITY Employer/Contact Person for practice
Clinical
Month/Year Month/Year verification and the person’s Complete
Practice Hours
Address, and Telephone #
Per Year

Dentist Online Application Instructions Revised June 2022 6


9960 Mayland Drive, Suite 300
Henrico, Virginia 23233
(804) 367-4538 (Tel)
(804) 698-4266 (eFax)
[email protected]
www.dhp.virginia.gov/dentistry

FORM C
CERTIFICATION OF DENTAL BOARDS
Please forward one form to each state dental/dental hygiene board where you hold or have ever held a dental/dental hygiene license.
Some states require a fee, paid in advance, for providing this information. To expedite, you may wish to contact the applicable state
board(s). Form C may be photocopied if copies are needed.

I am making application for licensure in Virginia by:


  Examination for Dental License   Examination for Dental Hygiene License   Dental Restricted Volunteer License
  Credentials for Dental License   Credentials for Dental Hygiene License   Dental Hygiene Restricted Volunteer License
  Dental Faculty License   Dental Hygiene Faculty License   Dental Reinstatement
  Dental Temporary Permit   Dental Hygiene Temporary Permit   Dental Hygiene Reinstatement

I, was granted License Type/Number , on by the State of


Month Date Year
. The Virginia Board of Dentistry requires that I submit evidence of the status of my license.
You are hereby authorized to release any information in your files, favorable or otherwise directly to the Virginia Board of
Dentistry at 9960 Mayland Drive, Suite 300, Henrico, Virginia 23233 or [email protected]. Your early
attention is appreciated.

Applicant’s Signature Applicant’s Typed/Printed Name Applicant’s Address

Executive Officer of the Board: please send this form directly to the Virginia Board of Dentistry.

State of Name of Licensee __ License #

Graduate of License Type __ Issued __

By:   Examination*   Credentials   Reciprocity with the State of   Endorsement with the State of

*If licensed by a state administered examination, please provide a score card or report which shows that testing included
live patients.

License is:   Current-Expires   Active   Inactive   Lapsed-Expired

Has applicant’s license ever been disciplined, suspended or revoked   NO   YES

If “YES”, give details and attach supporting documentation (Finding of Fact, Conclusions of Law, Orders):

Comments, if any:

SEAL Signature Title Date

Print Name

Dentist Online Application Instructions Revised June 2022 7


9960 Mayland Drive, Suite 300
Henrico, Virginia 23233
(804) 367-4538 (Tel)
(804) 698-4266 (eFax)
[email protected]
www.dhp.virginia.gov/dentistry

EMPLOYMENT VERIFICATION
(Optional Form)
(MUST BE COMPLETED BEFORE A NOTARY PUBLIC)

Name of Employing Dentist(s) or Agency:

Complete Mailing Address:

Telephone Number: Fax Number:

Email Address

“I, D.D.S./D.M.D./agency representative,


(Print name & Title of the Employing Dentist or Agency Representative)

certify that , was employed by me as a


(Print Applicant/Employee Name) (Print Job Title)

from / / to / / , in the clinical, ethical and legal practice of a


Month Day Year Month Day Year

.
(Job Title)

Dentist’s/Agency Representative Signature Date

State of

County/City of

Sworn and subscribed to, before me, this day of ,


Day Month Year

My commission expires on .
Month Day Year

Signature of Notary Public


SEAL/STAMP

Print Name

Dentist Online Application Instructions Revised June 2022 8

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