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STATE OF ALASKA

DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT

DIVISION OF OCCUPATIONAL LICENSING

BOARD OF DENTAL EXAMINERS

333 Willoughby Avenue, 9th Floor

P.O. Box 110806

Juneau, Alaska 99811-0806

(907) 465-2542

E-mail: license@dced.state.ak.us

DENTAL SPECIALTY LICENSE APPLICATION

Pursuant to Sec. 08.36.244, a licensed dentist may not hold out to the public as being especially qualified in a branch of dentistry by

announcing through the press, sign, card, letterhead or printed matter, or any means of public advertising, using such terms as

“specialist,” or inserting the name of the specialty, or using other phrases customarily used by qualified specialists that would imply

to the public that the dentist is so qualified, without first securing a specialist’s license, as provided in this chapter.

REQUIREMENTS FOR SPECIALIST LICENSE - AS 08.36.246, AS 08.36.247

Applicants must hold a current Alaska dental license and be a diplomate or the equivalent of the appropriate specialty board, or be

eligible to be examined for diplomate status as documented by an organization recognized by the American Dental Association. The

following documents must be on file before your application will be reviewed for a specialist license:

Completed and notarized application.

2. Certified true copy of certificate or other proof acceptable to the board that you have completed as many academic years of

advanced education in the specialty as are required by the appropriate specialty board in a program accredited by the

Commission on Accreditation of the American Dental Association or its successor agency; or a notarized statement that you

limit your practice exclusively and will ethically announce limitation of your practice in accordance with the Principles of Ethics

and Code of Professional Conduct of the American Dental Association.

3. Statement of Ethical Standards (including limitation of practice to specialty) according to 12 AAC 28.905.

Application fee of $50.00 (NONREFUNDABLE).

Specialist license fee of $100.00.

PERMIT FOR ADMINISTRATION OF GENERAL ANESTHETIC AGENT OR AGENTS

application fee of $50.00 (NONREFUNDABLE) not due if application for specialist license and general anesthetic permit

submitted at same time;

Permit fee of $100.00; and

certified true copy of your certificate verifying that you are a diplomate of the American Board of Oral Surgery, or member of

the American Society of Oral Surgery; or

verification that you have fulfilled not less than 36 months of oral surgery advanced education approved by the Council on

Dental Education of the American Dental Association; or

verification that you are a diplomate of an American Dental Association Specialty Board and meet the minimum requirements

in anesthesiology as recommended by the American Board of Oral Surgery; or

verification that you have completed a minimum of one year of advanced training in anesthesiology in an accredited program

beyond the undergraduate dental school level.

NOTE:

To obtain a “certified true copy,” you must present the notary with the original document as

well as a photocopy. You must make a written statement that this is the original and a

photocopy of this original. The notary will then notarize your signature regarding your

statement.

08-1486 (Rev. 02/01)

Form 08-1486 - Dental Specialty License Application - Alaska Department Of Community And Economic Development

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