DENTAL SUPPORT ORGANIZATION
BUSINESS SUPPORT SERVICES
ADDENDUM
Form 3804
Rev. 04/2016
Submit to:
SECRETARY OF STATE
Registrations Unit
P O Box 13193
Austin, TX 78711-3193
512-475-0775
Include with the Dental Support Organization Registration when number of dentists exceeds space provided.
This space reserved for office
use only
Dentist Name:
Name of Professional Entity or Dental Practice:
Business Address
(Please include street address, city, state and zip code):
Describe all business support services provided:
Dentist Name:
Name of Professional Entity or Dental Practice:
Business Address
(Please include street address, city, state and zip code):
Describe all business support services provided:
Dentist Name:
Name of Professional Entity or Dental Practice:
Business Address
(Please include street address, city, state and zip code):
Describe all business support services provided:
