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South Dakota State Board of Dentistry

PO Box 1037, 106 W. Capitol Ave., Pierre, SD 57501-1037

Ph: 605-224-1282 Fax: 605-224-7426

e-mail: :pat@

TO: Applicants requesting dental licensure in South Dakota

FROM: Pat Stearns, Administrative Assistant

SUBJECT: Dental Credential License Application

This application is for dentists who have not taken the CRDTS or WREB exam within the last 5 years and have been practicing dentistry in another state for at least 3 of the last 5 years.

All applications must be in the board office at least 30 days before the board meeting. Please DO NOT submit required items separately (except license verifications from state boards). It is important that you send all required information at one time to ensure accuracy and avoid confusion. Incomplete applications will be returned.

Upon the Board's verification of all materials, you will be sent the jurisprudence examination and a copy of the Dental Practice Act. Please return the exam with an exam fee of $50 to the board office on or before the date on the cover of the exam. Once you have passed the exam, you will be required to appear for a personal interview with the Board at its next meeting.

Board Meeting Dates

October 19, 2007

January 4,2008

June 13, 2008

You must be registered with the board office to administer general anesthesia, parenteral sedation or nitrous oxide. Applications are available on line or contact the board office for applications.

If you have any questions or need assistance, please contact me at (605) 224-1282.

Requirements for Dental Licensure by Credential Verification

SOUTH DAKOTA CODIFIED LAW, Chapter 36-6A-47. Licensing of dentist or hygienist from another state - Proof of character and professional standing - Examination on South Dakota rules. If an applicant for licensure is already licensed in another state to practice dentistry or dental hygiene, the Board of Dentistry may issue the appropriate dental or dental hygienist license to the applicant upon evidence that:

(1) The applicant is currently an active, competent practitioner.

(2) The applicant has passed a standardized national comprehensive test selected by the Board, and has practiced at least three years out of the five years immediately preceding application.

(3) The applicant currently holds a valid license in another state.

(4) No disciplinary proceeding or unresolved complaint is pending anywhere at the time a license is to be issued by this state.

(5) The licensure requirements in the other state are in the judgment of the Board the same as or higher than those required by this state.

6) The applicant is of good moral character.

7) The applicant successfully passes an examination concerning the laws of the state of South Dakota relating to dentistry and the rules of the Board.

AN APPLICANT FOR LICENSURE BY CREDENTIALS

MUST SUBMIT THE FOLLOWING ITEMS:

ADMINISTRATIVE RULE: Chapter 20:43:03:04. Requirements for licensure of dentists and dental hygienists by credential verification. To receive South Dakota licensure as a dentist or dental hygienist under credential verification, an applicant must meet the requirements of SDCL 36-6A-47. In addition, the candidate must meet the following requirements:

(1) Complete the proper application form and submit an application fee of $425 for dentists and $100 for dental hygienists at least 30 days before the board meeting;

(2) Submit a physician's statement attesting to the applicant's physical and mental condition.

(3) Appear for a personal interview conducted by the Board of Dentistry, on dates to be set by the Board.

(4) Have passed the national boards and regional boards and submit a copy of the grades.

(5) Submit a certified letter verifying the license number and status of such license from the board of dentistry in each state in which the applicant has been licensed. PLEASE HAVE LETTERS SENT DIRECTLY TO THE SD STATE BOARD OF DENTISTRY.

(6) Submit a copy of the diploma or a letter from a school official verifying that the applicant has graduated.

(7) Submit a copy of the applicant’s birth certificate.

(8) Submit a copy of the applicant’s current Healthcare Provider or Professional Rescuer (CPR) card.

(9) Submit a recent notarized photograph.

Pg. 1

South Dakota State Board of Dentistry

Credential Verification Application - Dentist

Instructions to the applicant:

Answer each question with specific information. If space is insufficient, attach an additional sheet.

Please print clearly or type answers.

1. FULL NAME: SS#:

2. OTHER NAMES USED: E-Mail

3. BIRTH DATE AND PLACE:

4. FULL HOME ADDRESS:

5. FULL OFFICE ADDRESS:

6. HOME PHONE: OFFICE PHONE:

7. Name, address, and occupation of parents:

8. Colleges attended other than dental - Location - Dates attended - Degree earned:

9. Dental colleges attended - Location - Dates attended - Degree earned:

10. Residency/internship – Location – Dates – Nature of residency/internship:

11. Submit the following information for EACH STATE in which you have been licensed:

STATE LICENSE # DATE RECEIVED STATUS

STATE LICENSE # DATE RECEIVED STATUS

STATE LICENSE # DATE RECEIVED STATUS

STATE LICENSE # DATE RECEIVED STATUS

STATE LICENSE # DATE RECEIVED STATUS

Pg. 2

12. Specialty (if applicable –attach proof of postdoctoral training)_____________________________

SDAR 20:43:04:01. Specialty practice – Qualifications. Those dentists who in any way purport or announce to the public specialty practices must have completed postdoctoral training which is recognized and approved by the American Dental Association Commission on Dental Accreditation. The following specialty programs are recognized by the Board of Dentistry: endodontics, oral pathology, oral and maxillofacial surgery, orthodontics, pediatric dentistry, periodontics, and prosthodontics.

13. Names of employers, partners, or associates and current address:

14. Dates of employment, partnership, or associates and reason for termination of each:

15. Employment other than as a dentist for past 10 years. Include date employed, address of employment, current full address of employer, position held and reason for termination:

16. Have you ever held a license OTHER THAN DENTAL? Include type, license #, and status:

17. List all present and past memberships in dental associations:

18. Submit the following information for three persons (other than those listed in 13 & 14) as references: Name - Full address - Occupation - Years known:

19. Submit the following information for three dentists (other than those listed in 13, 14 & 18) for use as references: Name - Full address - Years known:

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20. Are you a citizen of the United States? yes no. If claiming citizenship other than by birth in the U.S., state the basis of such claim and EXHIBIT PROOF. If naturalized, state the date, name, and location of the Court with the Certificate and Petition numbers.

If not a citizen, complete - AFFIDAVIT

I, (name)___________________________________, being duly sworn on oath, depose and

swear that I intend to become a citizen of the United States of America.

_______________________________________

Signature of Applicant

State of _________________________ Subscribed and sworn to before me

County of _____________________ this ________ day of _______________ 20_____

_________________________________________

Notary Public

ALL APPLICANTS MUST PROVIDE A NOTORIZED PHOTOGRAPH

I, _______________________________________, on being duly sworn, says that he or she is the person referred to in the above Application of License to practice as a Dentist in the State of South Dakota, and that all the statements therein contained are each and all strictly true in every respect and that the attached photograph is a true likeness of the applicant.

Subscribe and sworn to before me

this ____________ day of __________________ 20________

______________________________________________

Notary Public

State of _________________________

ss.

County of _______________________

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Please answer yes or no to the following questions

1. Have you ever been convicted of a felony? yes no

2. Have you ever been treated for chemical dependency? yes no

3. Have you ever been treated for mental disability? yes no

4. Have you ever had disciplinary action taken against your license in any other state for any

reason? yes no

5. Were you released from the military be any means other than an honorable discharge?

yes no

6. Are you in any way using fraud or deception in applying for a license to practice in South

Dakota? yes no

EXPLANATION OF ANY YES ANSWERS FOR QUESTIONS:

I have read and understand the above questions. I declare and affirm under the penalties of perjury that this application has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I also understand that if investigation shows any of the answers to be untrue, my license will be revoked according to SDCL 36-6A-59.

Signature of Applicant Date

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Authorization and Release

South Dakota State Board of Dentistry

I, ___________________________________, having filed an application for a license to practice dentistry/dental hygiene in the state of South Dakota, hereby apply for verification of my credentials and consent to have an investigation made as to my moral character, professional reputation and fitness for the practice of dentistry/dental hygiene. I agree to give any further information, which may be required in reference to my past record, I understand that I will not receive and am not entitled to a copy of the report or to know its contents, and I further understand that the contents of the report are privileged. I understand that I will be afforded a reasonable opportunity to rebut or explain any adverse information disclosed by the investigation.

I also authorize and request every person, firm, company, corporation, governmental agency, court, association or institution having control of any documents, records, and other information, or pertinent data to permit the South Dakota Board of Dentistry or any of its agents or representatives to inspect and make copies of such documents, records, and other information.

I hereby release, discharge, and exonerate the South Dakota State Board of Dentistry, its agents and representatives, and any other person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records and other information.

I understand that the State Board of Dentistry cannot accept any altered Authorization and Release forms.

I have read the foregoing document and have answered all questions fully and frankly. I declare and affirm under the penalties of perjury that this application has been examined by me, and to the best of my knowledge and belief, is in all things true and correct.

Signature of Applicant Date

Subscribe and sworn to before me

this ____________ day of __________________ 20________

______________________________________________

Notary Public

State of _________________________

ss.

County of _______________________

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Board Members

James Nyberg, DDS

G. Randy Sachau, DDS

Audrey Ticknor, RDH

Joan Adam

Roger Wilson, DDS

Robin Hattervig, DDS

Geoffrey Johnson, DDS

Paste Photo Here

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