Relocation Address Due to Natural Disaster

Relocation Address Due to Natural Disaster
If you have relocated due to a natural disaster and need to change your address on file with the Florida Board of Dentistry, please complete the form below and your FDA family will work with the Board of Dentistry staff to have the address associated with your dental license updated as soon as possible.
Full Name*

First NameLast Name
ADA Number
Cell Phone*

Area CodePhone Number
FL License #*
Please include your designated prefix (i.e DN)
Old Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
New Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: