Change Request Form

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Dental Directory > Change Request Form

Change Request Form

If you prefer, you may print this form and fax to (804) 864-7783 or mail to the address below.

First Name*:

Last Name*:

VA License*:

Contact Phone Number:*

Email:

* Indicates Required Field

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For any questions, problems or needed corrections please contact Seema Sked, MBA

Virginia Department of Health - Division of Dental Health
109 Governor St., 9th Flr., Richmond, VA 23219
Phone: (804) 864-7784