Fictitious Name Request Form

ASBDE Request For Approval Of A Fictitious Name Form

Complete the form below and submit for Board approval.

Fictitious Name Requested(Required)

Name of Dentist Requesting Fictitious Name:(Required)

First Last

Email(Required)

Phone(Required)

Specialty:

None-general

Oral medicine

Orthodontics

Dental anesthesiology

Oral pathology

Pediatric dentistry

Endodontics

Oral surgery

Periodontics

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Each fictitious or corporate name shall be registered with the Board by a licensed dentist who must be associated with the dental facility and who shall assume responsibility for compliance with the section. Each fictitious or corporate name must be approved by the Board prior to the use of the name. Names which in the judgment of the Board are false, misleading or deceptive will be prohibited. There will be only one of a kind fictitious or corporate name issued. To issue the same name more than once would be in the opinion of the Board false, misleading or deceptive. -Article VI: “Name of Practice”, Rules & Regulations

Boards & Commissions

ASBDE Request For Approval Of A Fictitious Name Form

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