Name Change

1. If a licensee submits a name change form prior to, or at the time of renewal, the license certificate will reflect the new name. 

2. Licensees may submit a name change form along with a renewal. Email dental.board@state.mn.us to request a printable renewal form. 

3. If submitting a name change along with the renewal and only need one license certificate, then the extra $10 name change fee is not required. Licensees automatically receive one license certificate after renewal. 

4. Check the box on the name change form indicating the surname you will use for licensure purposes. 

5. Include a photo copy of the legal document which changes your name. (Marriage certificate, court ordered name change, or divorce decree. If the legal document is a divorce decree then include the first page, the page with your legal name change, and the last page with the judge’s signature.) Only a photo copy produced on a copier machine is needed and not an original. Documents are shredded after processing and not returned. 

6. The name change form must be notarized. 

7. We can only accept checks (and money orders, as long as they do NOT say "mobile deposit prohibited") Cash and credit card are not accepted.