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Get Maine Local Anesthesia Renewal Online Form

Payable to: 161 Capitol Street Maine Board of Dental Examiners 143 State House Station Augusta, ME 04333 Tel: (207)287-3333 / Fax: (207)287-8140 Dental Hygiene Application for Renewal of Local Anesthesia Permit Renewal Fee: $40.00 * * * Please sign before mailing * * * Required fields are indicated by an asterisk (*) *Name *Dental Hygiene License # *Address *Local Anesthesia Permit # *Address Home Phone # *City/State/Zip Work Phone # Please list the dentist(s) who are supervising you w.

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