MS.GOV
Mississippi State Board of Dental Examiners
Licensure Verification Order Form
Fill in ALL applicable information. Payment and Form may be mailed to the Board, or the Online Payment Portal may be used.
NO PERSONAL CHECKS WILL BE ACCEPTED.
License Type
*
Licensee
First Name
*
Middle Name
Last Name
*
License Number
*
Licensee Phone Number
*
Licensee Email Address
*
Office/State Board Information (Verification will be mailed to the address below. PLEASE do NOT enter the MS Dental Board address)
Office/State Board
*
Address Line 1
*
Address Line 2
City
*
State
*
Zip Code
*
Mississippi State Board of Dental Examiners