Change Request Form

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Dental Directory > Change Request Form

Change Request Form

Please use this form to make updates or changes to your information on this website

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:

Change Information: Please indicate in the box below the information that needs to be changed or updated on the dentist directory.

Free Continuing Education Opportunity. We will be offering a tuition-free CE course regarding the care of children with special health care needs and very young children. Possible topics include an overview of special health care conditions, patient behavioral management techniques, and infant oral health assessment and prevention. If you are interested, please indicate in the box below, and make sure you provide your email address above.

* Indicates Required Field

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For any questions, problems or needed corrections please contact Kami Piscitelli

Virginia Department of Health - Dental Health Program
109 Governor St., 8th Flr., Richmond, VA 23219
Phone: (804) 864-7804