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Change of Address

When you change your office address, don't forget to contact the MDA, state of Michigan and other groups with your address change.

Who to Contact

Michigan Dental Association
Call Patti Fox at 800-589-2632 or 517-372-9070. The MDA will contact the American Dental Association and your local component society for you. If you prefer, use the MDA's online Change of Address form (bottom of page).

Additionally, the MDA offers a Change of Address Checklist to help you plan your move. Download it here!

Michigan Board of Dentistry/Office of Health Services
Call (517) 335-0918 for a change of address form. Or, submit a copy of your license (preferred) or your license number, old address and new address to Office of Health Services, P.O. Box 30670, Lansing, MI 48909-8170. This will also change your Michigan controlled substance license.

Michigan Consumer and Industry Services Bureau of Health Services - Licensing Division
The Licensing Division provides a Data Change/Duplicate License Form on its website at www.cis.state.mi.us/bhser/lic/home.htm, as well as other important licensing information. Completed forms can be faxed to (517) 373-2179.

Drug Enforcement Administration
Call the DEA at (313) 234-4000, or submit your old address, new address, DEA number and signature to DEA, 431 Howard St., Detroit, MI 48226, attention: Annie. If you are moving to Michigan from another state, please submit a copy of your Michigan license and Michigan controlled substance license.

Department of Radiological Health
Call Bob Sabo or Judy Hengesbach at (517) 241-1989, or write the Michigan Department of Consumer & Industry Services, Bureau of Health Services Radiation Safety, P.O. Box 30658, Lansing, MI 48909 to request a new application form.

If your home address changes or if you obtain an e-mail address or fax machine, please let the MDA know the appropriate address or phone number.

Change of Address Form

Personal Information

 (If you have no email address, please enter N/A.)

What address are you updating?

Complete the corresponding sections below.

New Home Address

_____

New Office Address

New Seasonal Address

Preferred Mailing Address

 Preferred Billing Address

* Required

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