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Indiana Professional Licensing Agency

PLA > Professions > Indiana State Board of Dentistry > Mobile Dental Facility Registration Mobile Dental Facility Registration

Click to download the Application for Registration of A Mobile Dental Facility .

Instructions:

  • All information provided must be accurate and complete.
  • The application must be typewritten or printed in ink legibly.
  • Include a two hundred dollar ($200.00) fee made payable to the "Professional Licensing Agency", and mail the completed application and supporting documentation to the address listed above.
  • All sections of the application must be completed.

A separate registration is required for each facility directly or indirectly owned or operated by the same person or entity in Indiana. A "mobile dental facility or portable dental operation" means either of the following:

  1. Any self-contained facility in which dentistry will be practiced, which may be moved, towed, or transported from one (1) location to another.
  2. Any non-facility in which dental equipment, utilized in the practice of dentistry, is transported to and utilized on a temporary basis at an out-of-office location, including, but not limited to:
    1. other dentists' offices;
    2. patients' homes;
    3. schools;
    4. nursing homes; or
    5. other institutions

Renewals: The owner (or corporate officer) will receive a renewal for the mobile dental facility registration at the same time that dentists and dental hygienists renew their licensure with the Professional Licensing Agency. It is the responsibility of the owner to renew the registration. The mobile dental facility registration shall be renewed on March 1 of even-numbered years. The registration is renewable at the discretion of the Board of Dentistry upon the payment of a fee of one hundred dollars ($100.00) and completion of the renewal application.

Address or Telephone Change: The operator of the facility is required to notify the Professional Licensing Agency and the Board of Dentistry within thirty (30) days of any change in address or telephone number of record. Your written notice must include the owner's name, mobile dental facility registration number, and both your old and new addresses and/or telephone numbers of record. Please send your written notice to: ATTN: Board of Dentistry, Professional Licensing Agency, 402 West Washington Street, Room W072, Indianapolis, IN 46204. If you want a new registration card, then please indicate in the letter that a new card is needed due to the change.

Once your application file is complete, including your supporting documentation, it will be reviewed by the Board of Dentistry for approval. The board typically meets once a month, so please allow sufficient time for processing.

Personnel Change: The operator of the facility shall identify and advise the board in writing within thirty (30) days of any personnel change relative to all licensed dentists and licensed dental hygienists associated with the mobile dental facility by providing the full name, address, telephone numbers, and license numbers.

Changes in Written Procedure for Emergency Follow-up Care: The operator shall advise the board in writing within thirty (30) days of any change in the written procedure for emergency follow-up care for patients treated in the mobile dental facility, including arrangements for treatment in a dental facility, which is permanently established in the area. The permanent dental facility shall be identified in the written procedure.

Questions: For questions about this application, please contact (317) 234-2054. You can also e-mail your questions to pla8@pla.IN.gov .

The rules regarding mobile dental facilities are located in Title 828 of the Indiana Administrative Code.