55 Wade Avenue Tulip Drive Catonsville, Maryland 21228 (410) 402-8511 application for dental licensure by examination dental pediatric fellows notice For Mailing List



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Maryland State Board of Dental Examiners

Spring Grove Hospital Center  Benjamin Rush Building

55 Wade Avenue Tulip Drive

Catonsville, Maryland 21228

(410) 402-8511

APPLICATION FOR DENTAL LICENSURE BY EXAMINATION

DENTAL PEDIATRIC FELLOWS

Notice For Mailing List:

The information collected on this application form is collected for the purposes of the Board’s functions under the Annotated Code of MD, Health Occupations Article, Title 4. Failure to provide the information may result in denial of your application. You have a right to inspect, amend, and request correction of this information. The Board may permit inspection of this information or make it available to others only as permitted by federal and State law. Under the Maryland Public Information Act, Annotated Code of Maryland, General Provisions Article, §4-333, the Board may provide, for a fee, a list of licensees’ names and addresses to professional associations and other entities. You may request in writing that your name be omitted from such lists.


Information for Veterans, Service Members, and Military Spouses
Please note the following:
“Veteran” is a former service member who was discharged from active duty under circumstances other than dishonorable within 1 (one) year before the date on which this application has been submitted. “Veteran” does not include an individual who has completed active duty and has been discharged for more than 1 year before the application for a license, certificate, or permit is submitted.
“Service member” is a an individual who is an active duty member of the armed forces of the United States, a reserve component of the armed forces of the United States, or the National Guard of any state.
“Military Spouse” is the spouse of a service member or veteran and includes the surviving spouse of a veteran, or a service member who died within 1 (one) year before the date on which the application for licensure is submitted to the Board.
Veterans, service members and military spouses are assigned an advisor to assist in the application process. In addition, the Board will expedite the processing of completed applications for veterans, service members, and military spouses. If you do not meet the education or training or experience requirements for licensure, your advisor will assist you in identifying programs that offer relevant education or training, or ways to obtain the necessary experience.
Your advisor is Deborah Welch. Ms. Welch may be reached at 410-402-8511. In Ms. Welch’s absence you may contact Ms. Sandra Sage at 410-402-8510.
Are you a:
Veteran  Yes  No Service Member  Yes  No Military Spouse  Yes  No

SECTION I – GENERAL INFORMATION

Name

(Last, First, Middle Initial):




Address of Record:

(Street Address)




City, State, Zip:





A. Social Security Number:    -   -    

(There is a statutory requirement that you disclose your social security number. It will be used for identification purposes only.)


B. Date of Birth:   -   -    
C. Home Phone Number:    -    -    
D. Work Phone Number:    -    -    
E. E-Mail Address:
F. Gender:  Female  Male

Are you of Hispanic or Latino origin? Yes  No 

(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)



G. Race/Ethnic Identification – Please check all that apply
Select one or more of the following racial categories:
1.  American Indian or Alaska Native (A person having origins in any of the original peoples of North or

South America, including Central America, and who maintains tribal affiliations or community attachment.)


2.  Asian (A person having origin in any of the original peoples of the Far East, Southeast Asia, or the Indian

subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)


3.  Black or African American (A person having origins in any of the black racial groups of Africa.)
4.  Native Hawaiian or other Pacific Islander (A person having origins in the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
5.  White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
H. Licensure in other states:

List other states or jurisdictions in which you hold or have held a dental license. Include license number(s).




State

License Number


























I. Maryland licensure:

Do you hold or have you ever held a Maryland Limited Dental License?  Yes  No If yes, License Number: ________



SECTION II - EDUCATION
A. School of Graduation (D.D.S., D.M.D., or equivalent) (Name, City, State, Country):

______________________________________________________________________________________
B. Date of Graduation: ___________________ Degree Earned: _____________________________

SECTION III – EXAMINATIONS
A. Have you passed Parts I and II of the National Board Examinations?  Yes  No
B. Date of examination: _______________ Location of examination: ___________________________________________
C. Have you passed all sections of the North East Regional Board examination?  Yes  No
D. Date of examination: _______________ Location of examination: ___________________________________________
E. Did you take the Curriculum Integrated Format examination?  Yes  No
F. Have you passed the Curriculum Integrated Format examination?  Yes  No
G. Date of examination: ________________ Location of examination: __________________________________________


SECTION IV – QUALIFICATIONS
A. Have you successfully completed at least a 2-year pediatric dentistry residency program at a dental school or a hospital authorized by any state and which is recognized by the Board?  Yes  No
Name of program: _______________________________ Institution at which completed: _________________________________

Date completed: ____________________________


B. Are you a pediatric dental fellow?  Yes  No

Name of Institution granting fellowship: ______________________________Date fellowship completed: ________________________


C. Have you completed at least a 2-year contractual obligation to provide pediatric dental services in a public health dental clinic operated by the State or a county or municipality of the State, or, in a federally qualified health center or Maryland qualified health center only to Medicaid, uninsured, or indigent patients or patients who otherwise qualify for dental care in a public health dental clinic?
Name of Clinic: _________________________________________ Dates of Contractual Obligation: From: _________To:__________
D. Have you limited your practice to the public health dental clinic, federally qualified health center, or Maryland qualified health center for which you have contractually agreed to provide pediatric dental services?  Yes  No
If you answered “No” explain: ____________________________________________________________________________________

SECTION V - CHARACTER AND FITNESS
If you answered “YES” to any question(s) in Section V – Character and Fitness, attach a separate page with a complete explanation of each occasion. Each attachment must have your name in print, signature, and date.

YES NO


  a. Has any licensing or disciplinary board of any jurisdiction, including Maryland, or any federal entity denied your application for licensure, reinstatement, or renewal, or taken any action against your license, including but not limited to reprimand, suspension, revocation, a fine, or non-judicial punishment? If you are under a Board Order or were ever under a Board Order in a state other than Maryland you must enclose a certified legible copy of the entire Order with this application.


  b. Have any investigations or charges been brought against you or are any currently pending in any jurisdiction, including Maryland, by any licensing or disciplinary board or any federal or state entity?
  c. Has your application for a dentist in any jurisdiction been withdrawn for any reason?
  d. Has an investigation or charge been brought against you by a hospital, related institution, or alternative health care system?
  e. Have you had any denial of application for privileges, failure to renew your privileges, or limitation, restriction, suspension, revocation or loss in privileges in a hospital, related health care facility, or alternative health care system?
  f. Have you pled guilty, nolo contendere, had a conviction or receipt of probation before judgment or other diversionary disposition of any criminal act, excluding minor traffic violations?
  g. Have you pled guilty, nolo contendere, had a conviction, or receipt of probation before judgment or other diversionary disposition for an alcohol or controlled dangerous substance offense, including but not limited to driving while under the influence of alcohol or controlled dangerous substances?
  h. Do you have criminal charges pending against you in any court of law, excluding minor traffic violations?
  i. Do you have a physical condition that impairs your ability to practice dentistry?
  j. Do you have a mental health condition that impairs your ability to practice dentistry?
  k. Have the use of drugs and/or alcohol resulted in an impairment of your ability to practice dentistry?


SECTION V - CHARACTER AND FITNESS (CONT’D)

YES NO

  l. Have you illegally used drugs?


  m. Have you surrendered or allowed your license to lapse while under investigation by any licensing or disciplinary board of any jurisdiction, including Maryland, or any federal or state entity?
  n. Have you been named as a defendant in a filing or settlement of a malpractice action?
  o. Has your employment been affected or have you voluntarily resigned from any employment, in any setting, or

have you been terminated or suspended, from any hospital, related health care or other institution, or any federal

entity for any disciplinary reasons or while under investigation for disciplinary reasons?
The Well Being Committee assists dentists and their families who are experiencing personal problems. The Committee has helped

many dentists over the years with problems such as stress, drug dependence, alcoholism, depression, medical problems, infectious

diseases, neurological disorders and other illnesses that cause impairment. For more information, dentists may visit

www.dentistwellbeing.com.



Incomplete applications will be returned and will be subject to a $50.00 application reprocessing fee.

Release and Certification:

I hereby affirm that I have read and followed the above instructions. I hereby certify that all information in this application is accurate and correct.


I agree that the Maryland State Board of Dental Examiners (the Board) may request any information necessary to process my application for dental licensure in Maryland from any person or agency, including but not limited to schools, colleges, or faculties of dentistry, wherever located, postgraduate program directors, individual dentists, government agencies, the National Practitioner Data Bank, the Healthcare Integrity and Protection Data Bank, hospitals and other licensing bodies, and I agree that any person or agency may release to the Board the information requested. I also agree to sign any subsequent release for information that may be requested by the Board.
I agree that I will fully cooperate with any request for information or with any investigation related to my dental practice as a licensed dentist in the State of Maryland, including the subpoena of documents or records or the inspection of my dental practice.
During the period in which my application is being processed, I shall inform the Board within 30 days of any change to any answer I originally gave in this application, any arrest or conviction, any change of address or any action that occurs based on accusations that would be grounds for disciplinary action under the Annotated Code of Maryland, Health Occupations Article, §4-315.

__________________________________________________ ________________________



Applicant Signature Date

NOTARY SECTION
State of ___________________, County of _________________, then personally appeared the above named
______________________________________, and signed and sworn to the truth of the foregoing statements in my

presence.


Notary Public: __________________________ My Commission Expires: __________________

SEAL

Application for Dental Licensure by Examination

Dental Pediatric Fellows
Check List
Please review prior to sending your application package to the Board.
Incomplete applications will be returned and will be subject to a $50.00 application reprocessing fee.
 1. Is your application completed front and back?


  • Did you sign and have the application notarized?

 2. Did you enclose the $450 non-refundable fee in a check or money order made payable to the Maryland

State Board of Dental Examiners?
 3. Did you enclose one photo that is between 2x2-inches and 3x3-inches with the required notarized

affidavit? Note that the photo will be affixed to your license. The photo must meet the following

guidelines: taken within the last 2 years to reflect your current appearance; front view of full face

from top of hair to shoulders; a natural expression; no hat; or head covering that obscures the hair

or hairline, unless worn daily for religious purposes; no sunglasses, headphones, wireless hands-free

devices or similar items; no other individuals or distractions in the photo. Photos copied or digitally

scanned from driver’s licenses or other official documents are not acceptable. In addition, low quality

vending machine or mobile phone photos are not acceptable. “Passport” photos are acceptable.

Unacceptable photos will be returned and shall delay the issuance of your license.
 4. Did you request that an original National Board score card be forwarded to the Maryland State Board of

Dental Examiners?


 5. Did you enclose a certified examination report from the North East Regional Board?
 6. Did you enclose an original letter signed by the Dean of the University of Maryland Dental School on

original letterhead, indicating that you have successfully completed a pediatric dental fellowship at the

University of Maryland Dental School?
 7. Did you enclose a certified letter with a raised embossed seal from the dental licensing authority of each

state in which the applicant holds an active dental license or ever held an active dental license, indicating

that the license is or was in good standing and whether the applicant: (a) is being investigated; (b) has

charges pending against the applicant’s license; (c) has been disciplined; (d) has been convicted or

disciplined by a court of any state or country?

 8. Did you enclose an original letter signed by an official of the public health dental clinic or Federally

qualified health center, or Maryland qualified health center, on their letterhead, indicating that you have

successfully completed at least a 2-year contractual obligation to provide pediatric dental care in

accordance with Health Occupations Article, § 4-303.1(b)(1)(iv)?
 9. A letter from the dean of the dental school at which the license is limited indicating that the applicant

possesses sufficient comprehension and communication skills in written and spoken English to enable the

applicant to adequately treat dental patients.
 10. Did you enclose documentation of legal name change (i.e. marriage certificate) if the documents sent with

the application are in another name?


 11. Did you enclose the Maryland Jurisprudence Examination and the notarized affidavit along with the

$50.00 non-refundable fee in a check or money order made payable to the Maryland State Board of



Dental Examiners?

MARYLAND STATE BOARD OF DENTAL EXAMINERS

GUIDELINES FOR DENTAL LICENSURE BY EXAMINATION
DENTAL PEDIATRIC FELLOW


The Board may not process a licensure application until each provision or requirement is met and each document is received. Please ensure that your application is complete before it is submitted.
The applicant shall:
a. Be of good moral character; and
b. Be at least 21 years old; and


  1. Holds a DDS, DMD, or an equivalent degree from a school, college or faculty of dentistry other than one located in the United States or Canada; and




  1. Has held a Maryland limited dental license in accordance with Health Occupations Article, § 4-303.1; and




  1. Has successfully completed at least a 2-year pediatric dentistry residency program at a dental school or hospital authorized by any state and which is recognized by the Board; and




  1. Has successfully completed a pediatric dental fellowship at the University of Maryland Dental School; and




  1. Has successfully completed a 2-year obligation to provide pediatric dental services in a public health dental clinic operated by the State or a county or municipality of the State or in a federally qualified health center or Maryland qualified health center only to Medicaid, uninsured, or indigent patients or patients who otherwise qualify for dental care in a public health dental clinic; and




  1. Has passed the North East Regional Board of Dental Examiners (NERB) examination; and




  1. Has passed the National Board Examinations; and




  1. Has passed the Maryland Dental Jurisprudence Examination; and




  1. A letter from the dean of the dental school at which the license is limited indicating that the applicant possesses sufficient comprehension and communication skills in written and spoken English to enable the applicant to adequately treat dental patients.


To apply for licensure, submit the Application for Dental Licensure by Examination – Dental Pediatric Fellow and enclose the following with your application:


  • A $450 non-refundable fee. Additional fees may be levied by the Board for investigative purposes.




  • A photograph that meets the requirements contained in the Checklist with the following statement: “The

picture is a true photograph of me.”


  • Original National Board score card. You must contact the National Board of Dental Examiners at 211 E. Chicago Avenue, Suite 1846, Chicago, IL 60611 or (312) 440-2678 or (800) 621-8099 and request that an Original Score Card be forwarded to the Maryland State Board of Dental Examiners at the address below.




  • Certified examination scores from the North East Regional Board of Dental Examiners (NERB) for the Examination in Dentistry. Applicants may make application for this examination by contacting NERB at (301) 563-3300.




  • A certified letter with the state seal affixed from each state in which you hold or have ever held a license, verifying that the license is or was in good standing and indicating whether any disciplinary action has ever been taken against the license.



  • Proof of completion of pediatric dental fellowship. An original letter signed by the Dean of the University of Maryland Dental School on original letterhead, indicating that the applicant has successfully completed a pediatric dental fellowship at the University of Maryland Dental School.




  • Proof of completion of a 2-year obligation to provide pediatric dental services. An original letter signed by an official of the public health dental clinic or Federally qualified health center, or Maryland qualified health center, on their letterhead, indicating that you have successfully completed at least a 2 year contractual obligation to provide pediatric dental care in accordance with Health Occupations Article, § 4-303.1(b)(1)(iv)




  • If applicable, evidence of legal name change, such as a marriage certificate or court documents.


Additional Requirements:


  • All applicants for licensure in Maryland must take the Jurisprudence Examination on the Dental Laws and Regulations of this state. If you have taken the Jurisprudence Examination as a condition for issuance of a Limited License, you are not required to take the examination a second time. If you have not previously taken and passed the examination, you must do so to obtain a license under this application.




  • It is an open book examination and is now available online at www.dhmh.md.gov/dental. If you choose to complete the online examination, please also complete the Affidavit form and return both documents to our office along with the Jurisprudence Examination fee of $50.00. Applicants may also take the examination at the Board’s offices Monday through Friday between the hours of 9:00 a.m. and 4:00 p.m. You will be scheduled for the exam after your completed application is reviewed.



Incomplete applications will be returned and will be subject to a $50.00 application reprocessing fee.

MAIL APPLICATION AND SUPPORTING DOCUMENTS TO:
Maryland State Board of Dental Examiners

Spring Grove Hospital Center

Benjamin Rush Building

55 Wade Avenue • Tulip Drive



Catonsville, MD 21228

ATTN: Licensing Unit


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