Business Entity Registration Change Form

Pursuant to A.R.S. § 32-1213(E), business entities are required to notify the Board, in writing, within 30 days, any change to the business entity's name, address, or telephone number; any change in the officers/directors; any change of dentists authorized to provide dental services; and/or the name of the custodian of records.

Online submission (Once all required fields are completed, a "Click to Sign" button will display at the bottom of your screen.)