Get Wa Doh 646-164 2014-2025

The WA DOH 646-164 form is an essential document for activating an expired dental license in the state of Washington. This guide provides clear, step-by-step instructions for completing the form online, ensuring that you submit a complete and accurate application.

Follow the steps to successfully complete the WA DOH 646-164 form.

1. Press the ‘Get Form’ button to access the WA DOH 646-164 online form and open it in your preferred editor.
2. Begin by filling in your demographic information. This includes your Social Security number, National Provider Identifier number if you have one, legal name (first, middle, and last), birth date, and place of birth (city, state, and country).
3. Provide your current address, including city, state, zip code, county, and country. This will be the permanent address associated with your application.
4. Enter your contact information, including phone, fax, and cell numbers, as well as your email address. Ensure all details are current to receive communications regarding your application.
5. Indicate if you have been known by any other names. If so, provide those names and ensure you notify the Department of Health in writing regarding any name changes.
6. List all other licenses, certifications, or registrations you have held since your Washington State credential expired, including details such as the state, profession, and year issued.
7. Detail your professional experience since your last credentialing, chronologically listing your positions and locations.
8. Fill in the required attestations, including the AIDS Education and Training Attestation, Disciplinary Action Attestation, and Continuing Education Attestation. Each section must be completed truthfully.
9. In the Applicant’s Attestation section, print your name clearly, date the application, and provide your signature. Make sure these details are accurate to avoid processing delays.
10. Review all completed sections for accuracy and thoroughness. Save your changes and prepare to submit your application by mailing it with the necessary documentation and fees.

Complete your application online today to activate your dental license smoothly.