Change of Address Form -- Iowa Dental Board

Forms › Change of Address

Please note: this webpage is still under development and may not function properly. If you are unable to get a change of address submission to work, please email or fax the information to this office. IDB@iowa.gov or 515-281-7969.

It is important that the Board office maintains accurate contact information concerning all licensees, registrants and permit holders in order to ensure that renewal notices and other important correspondence is sent to an appropriate address.

Board rules also require all licensees, reginstrants and permit holders to inform the Board of a change of legal name or address within sixty (60) days of such change.

For Name Changes. If you need to inform us of a name change, you must submit a written notarized copy of the legal documents that change the name. Mail this information to:
Iowa Dental Board
400 S.W. 8th Street, Suite D
Des Moines, Iowa 50309-4687

For Duplicate Renewal Card/Certificate with New Address. If you need a new renewal card or certificate with your updated address, you must submit a request for a duplicate card or certificate along with the required fee.

Request duplicate certificate/renewal card
Fees

If your home or employment address has changed, please complete and submit the following information.

Please note: If you are a dentist, your default mailing address will be your work address unless you notify the Board in writing indicating another preference. If you are a dental hygienist or dental assistant, your default mailing address will be your home address unless you notify the Board in writing indicating another preference.

Personal Information

Name (Required)

License Number (Required)

Date of Birth (Required)

E-mail Address (Required)

An e-mail address is required if you would like us to respond to this form.

Profession (Required)

Change for... (Required)

New Home Address

Address (Line 1)

Address (Line 2)

City

State

Zip Code

New Work Address

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Check this box when you have completed this form, then click "submit" to send the form. This box must be checked and by doing so you are certifying that the information given herein is true and correct to the best of your knowledge.