Request a Replacement Wall Display License (Decorative Certificate)

Dentists and Dental Hygienists use this form to replace a lost or destroyed Wall Display License.   The Wall Display License bears the signatures of the State Board of Dental Examiners.

Request Process

  1. The Affidavit of Destruction or Loss of Texas Dental/Dental Hygiene License must accompany this request. (Included with PDF of form below.)
  2. Mail this form, the affidavit and your non-refundable fee to the TSBDE at the address listed on the form.  (See form for current fee.)
  3. Do not complete this form if you are making a Name Change.  A new Wall Display License will be issued when you mail a Name Change Request Form to the TSBDE.

Wall License Replacement Request Form