State of Maine Board of Dental Examiners
Email Complaint Form
You may use this electronic form to file a complaint against a provider
(a dentist, denturist, dental hygienist or dental radiographer). Please note that the State of Maine Board of Dental Examiners has no authority to assist you with fee disputes with your provider, unless the provider is demanding payment for services not rendered. If you have a complaint concerning a fee dispute, please contact the Maine Attorney General's Office, Consumer Protection Unit, at http://www.state.me.us/ag/consumer.htm and/or the Maine Dental Association

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Person Registering Complaint
Please provide the following information so that we may acknowledge receipt of your complaint and that we may contact you should we need further information.
  The submission of this form does not provide us with your Email address.
Your
Name: 
First Middle Last
 
Address:
City:
State:
Zip Code:
Daytime Phone: Include Area Code 
Patient's Date of Birth:  
If you wish you may provide an Email address.
  Your Email address is 

Patient Information
Is the patient information the same as the complainant information?
If patient information is NOT the same as the complainant information please provide the information below.

Patient's
Name: 
First Middle Last
 
Address:
City:
State:
Zip Code:
Daytime Phone: Include Area Code 
Patient's Date of Birth:  

Complaint Filed Against
Please supply specific information regarding the provider (dentist, denturist, dental hygienist or dental radiographer) you are filing a complaint against, to include the provider's full name and practice location.

Provider's
Name: 
First Middle Last
 Is the provider a  
Address:
City:
State:
Zip Code:
Daytime Phone: Include Area Code 
Note:  If you are filing a complaint against several providers, you must send each one separately.  To do this, complete this form, send it and then back up and fill out the information for the next provider.  The rest of the information will still be filled in.

Narrative Information
Provide detailed information regarding your complaint to include date(s) of treatment.

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If you should encounter any problems with this process, or wish to speak to someone,
please contact Teneale Johnson, or call her at (207) 287-3333.