Denturist Alternate Location Renewal Request

Renewal requirements:

This form may be used to renew your denturist alternate location credential if your denturist license is in active status. If you need information about your credential please check our Provider Credential Search. Once you find your record, click on your credential number to find your credential's expiration date and status.

You must complete this form for each denturist alternate location renewal.

NOTE: You must complete a denturist alternate location license application (PDF) if you have changed locations. Don't use this form.

* Indicates required field
Your Information:

* First Name:

Middle Name:

* Last Name:

* Date of Birth (mm/dd/yyyy):

* List your denturist alternate location credential number. (ALXXXXXXXX)

* List your denturist credential number. (DNXXXXXXXX)

Contact Information:
Phone Number:
Fax Number:
Cell Phone Number:
Email Address:
By submitting this form, I affirm the information provided for the renewal of my Denturist Alternate Location is true and accurate to the best of my knowledge.  
Your renewal will be processed within three (3) business days of submittal if your denturist license is in active status. The submittal date will be the effective date of your renewal. You will receive an email from Washington State Department of Health staff notifying you the renewal has been processed.