Georgia board of dentistry a division of the georgia

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APPLICATION FOR DENTAL LICENSURE BY CREDENTIALS

GEORGIA BOARD OF DENTISTRY

A Division of the Georgia Department of Community Health 2 Peachtree Street, N.W. 6th Floor Atlanta, Georgia 30303 gbd.

Please read the instructions carefully and be familiar with the laws and rules governing the practice of dentistry in the State of Georgia. Visit the board's web site for information: gbd.

**Important**

The Board cannot process incomplete applications. If any item is missing, incomplete or incorrect, your application cannot be reviewed by the Board.

Please review this application before you submit it to ensure that all information and documentation is complete and correct.

Incomplete applications are maintained in the Board office for a period of one (1) year. After such time the application is rendered void and the applicant must reapply and pay all required fees.

Application Checklist The following checklist is an important part of your application. Please use this

checklist to ensure that you submit a COMPLETE application.

The $3025 non-refundable application fee payable by check or money order to the Georgia Board of Dentistry must be included with your application. Checks returned for

insufficient funds will be assessed a service charge pursuant to O.C.G.A. ? 16-9-20.

1. NOTARIZED APPLICATION: Completed application form accompanied by the appropriate fee. Your application will not be processed unless the fee and all supporting documents are received. If licensure is granted, the license will be required to be renewed by the last day of December in ODD numbered years, regardless of when you were originally licensed. The licensure process could take up to a minimum of 30 days after submission of a completed application. Further, all credentials applications must be considered by the Board. Plan your application time accordingly.

2. APPLICABLE LAWS AND RULES: O.C.G.A ? 43-11-41 and Board Rule 150-7.04 give the specific requirements for licensure by credentials. These laws and rules may be found on the board's website at gbd..

3. LICENSE VERIFICATION: Official license verification for every dental license ever held. Each verification must indicate the date of licensure, the licensure status (active, inactive, expired, revoked, etc.) standing of license, any

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disciplinary charges made against you by the licensing board and the result of these actions. Theapplicant must provide a copy of the formal complaint/pleading, outcomes, and a personal written explanation for each instance of discipline. You should call each state board about fees for these services. The verification must be submitted with your application IN THE ORIGINAL SEALED ENVELOPE FROM THE BOARD OF EACH STATE, and must be dated within four months of Board receipt of your application.

4. DEGREE TRANSCRIPT: An official transcript which documents graduation with a D.D.S. or D.M.D. degree from a dental school which is accredited by the American Dental Association Commission on Dental Education. The transcript must be IN THE ORIGINAL SEALED ENVELOPE FROM THE COLLEGE. Graduates from non-accredited schools please see Board Rule 150-3-.04 and O.C.G.A.? 43-11-40(a)(1)(A) and (B).

5. NATIONAL BOARD SCORES: National Board Dental Examination Scores (NBDE) from the ADA Joint Commission on National Dental examinations (Part I and Part II examinations) are required. The ADA will no longer send results via mail. You may access your national board results online by going to . Download your results and submit with your application. If you have any issues accessing this information, please contact the ADA at 800-232-1694 or nbexams@.

6. CLINICAL LICENSING EXAMINATION: Certification that the applicant

has successfully completed with a passing score in each section, a clinical licensing examination in general dentistry conducted by a regional or state testing agency that meets the following criteria:

a. Anonymity between candidate and examiners. b. Psychometrically valid procedures for standardization and calibration of

the examiners. c. A post examination analysis of the scoring for single examination

aberrations.

Such verification shall state that the examination included clinical testing on live patients in the following areas: a. Periodontal clinical abilities testing. b. Completion of at least two of the following four areas:

a. Class II Amalgam preparation and finish b. Cast Gold preparation and finish, Class II inlay, onlay, partial or full

coverage crown c. Class II Composite preparation and finish d. Class III Composite preparation and finish

Such verification shall also include clinical testing on mannequin or model in the following areas: a. Endodontic clinical abilities testing access opening and root canal fill b. Prosthodontic clinical abilities testing of partial denture, full denture and

implant case planning.

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Additional clinical abilities testing modules successfully completed will be considered as substitutes where appropriate for the above requirements if those modules test a similar skill set.

If the examination completed did not require testing in the above listed modules, the application will be considered on an individual basis.

IMPORTANT: Clinical scores MUST be broken down by section, with a score for each of these sections. All candidates must have taken and passed a clinical examination with a score of 75 or greater on all sections of the examination. The clinical examination MUST be Board approved.

7. JURISPRUDENCE EXAMINATION: Successful completion of the Jurisprudence Examination with a score or 75 or higher. The Jurisprudence examination may be taken as an open book exam. The examination and "law and rules" governing the practice of dentistry in Georgia may be obtained on the Georgia Board of Dentistry website at: gdb.. Score is only valid for one (1) year.

8. NATIONAL PRACTITIONER DATA BANK: To obtain a self query from the NPDB-HIPDB, please visit npdb. or call the Customer Service Center at 1-800-767-6732.

If the National Practitioner Data Bank (NPDB) report provides any disciplinary action, certified copies of any pending or final disciplinary actions or malpractice actions against applicant must be submitted. All applicants must submit a NPDB report along with the completed application. The NPDB report must be dated within four months of the submission of the application. The ONLY applicants exempt from the requirement of NPDB report submission are those applicants within 6 months of dental school graduation and have never been issued a dental license in any state or U.S. territory.

The NPDB report must be received in the ORIGINAL SEALED ENVELOPE FROM NPDB. Applicants who have disciplinary or malpractice case(s) (open & closed) will be considered for licensure on a case- by-case basis, after receipt of all required application materials. For each case, the applicant must submit: 1) A copy of the formal complaint pleadings filed by the plaintiff/complainant or State Regulatory Agency, 2) A copy of the final action, disposition, or settlement, 3) A personal explanation of the disciplinary action or the malpractice claim, and 4) Any further information requested by the Board in separate communications.

9. COPY OF COURT DOCUMENTS OR AFFIDAVITS explaining any discrepancies of the applicant's name if documents submitted bear different name(s).[i.e. marriage certificate, divorce decree, legal name change]

10. CPR: A photocopy of current CPR certification in compliance with Board Rule 150-3-.08.

11. DEA REGISTRATION: Controlled Substance Registration Certificate issued by the Drug Enforcement Administration (Form DEA-223). If applicant is not currently registered with the DEA, please submit a letter explaining such.

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12. EMPLOYMENT AFFIDAVIT: An affidavit from the applicant stating employment for the five years immediately preceding application: (A) The dates and locations where the applicant has practiced dentistry; and (B) The applicant has been in full time clinical practice of a minimum of 1000 hours per year in the hands on treatment of patients. Training programs do not qualify as full time clinical practice. Please note that the practice requirement cannot be waived as it is required by law.

13. MALPRACTICE QUESTIONNAIRE: Complete one for each suit and attach the necessary documentation. (If not applicable, write N/A on the form sign, date, and return with application).

14. EXPEDITED APPLICATION REVIEW: Military spouses, service members, and transitioning service members qualify for expedited application review and should review Board Rule 150-7-.06 for details.

Upon receipt of the license, the applicant by credentials must establish active practice in this state within two years of receiving such license or the license shall be automatically revoked. Relocation: If you relocate during the time that your application is being processed, you must notify the Board of your new address in writing by fax to (470) 386-6124 or mail. This will enable you to receive Board correspondence.

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Listing of States accepted for Licensure by Credentials

Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico **New York North Carolina North Dakota Ohio Oklahoma

Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

**Yes, provided completion of a clinical licensing examination and not PGY 1.

States not accepted for Licensure by Credentials ? Dental and Dental Hygiene***

Florida

***Please refer to Georgia Rule 150-7.04 and O.C.G.A. ? 43-11-41 for dentists, and Georgia Rule 150-7-.05 and O.C.G.A.? 43-11-71.1 for dental hygienists

Please note all application fees are nonrefundable and non-transferable. This list is subject to change and will be updated on an as needed basis.

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Do Not Write In This Section: Receipt#: Amount: Applicant #: Initials/Date:

GEORGIA BOARD OF DENTISTRY

Address: Telephone #: Fax #: Website:

2 Peachtree Street, N.W., 6th Floor, Atlanta, GA 30303 (404) 651-8000 (470) 386-6124 gbd.

Application For: Dental Licensure by Credentials Obtained By Method ? Credentials - $3,025 Non-refundable/Non-transferable application fee. Checks returned for non-sufficient funds will be assessed a $40 service charge pursuant to O.C.G.A.? 16-9-20

DISABILITY- If you have a disability and may require an accommodation, you must contact the Board to obtain the REQUEST FOR DISABILITY ACCOMMODATIONS GUIDELINES. VETERANS PREFERENCE POINTS- Veterans may be eligible for special benefits in testing. For more information, contact the Board office. Submit copy of DD-214 with your application.

I am a military spouse, service member, or transitioning service member, and I am requesting expedited

application review. I understand that I may be required to submit a copy of my PCS orders, a copy of my

spouse's PCS orders and my marriage certificate, or other documentation as requested by the Board.

Yes

No

Part I: Personal Information

1. Name:

Last

First

Middle

Maiden

Name as shown on examination records or transcripts (if different)_

2. Social Security Number*: _______ - ______-_______ 3. Date of Birth:_________________________

4. Physical Address: ____________________________________________________________________

(Street)

(Apt. #)

(City/State/Zip)

(P.O. Box Not Acceptable)

5. Mailing Address: ____________________________________________________________________

(Street)

(Apt. #)

(City/State/Zip)

If you are granted a license, your name, mailing address and license number are public information.

_

6. E-Mail Address: ________________________________________

7. Telephone #: Home ( ) _________________ Work ( ) ___________________

Other ( ) _________________

8. Military Service: _________________________ Dates of Service: __________________________

Honorable/Dishonorable Discharge: _____________________________

*This information is authorized to be obtained and disclosed to state and federal agencies pursuant to O.C.G.A. ?19-11-1 and

O.C.G.A. ?20-3-295, 42 U.S.C.A. ?551 and 20 U.S.C.A. ?1001. It may also be disclosed to the National Practitioner's Databank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) or other licensing boards, or other

regulatory agencies for license tracking purposes. **Submit copy of Registration Card.

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