(A) No licensed dentist shall participate in the oral health access supervision program as provided in sections 4715.36 to 4715.374 of the Revised Code, unless such dentist possesses a permit issued by the Ohio state dental board.
(B) In order to receive such a permit, the licensed dentist shall apply on a form prescribed and provided by the state dental board, submit the application fee of twenty dollars, and provide the following information:
(1) Dentist's name;
(2) Ohio license number; and
(3) Current practice address.
(C) The state dental board shall issue an oral health access supervision permit to a dentist who is in good standing with the board and satisfies all the requirements of this rule.