Annual Diplomate Fee Renewal Renewal - American Dental Board of Anesthesiology Name * Credentials * Home Address * Office Address * Email Address * Work Phone * Cell Phone * Fax Phone The ADBA Board of Directors would like to list your name to the ADBA website as a Diplomate. The listing would include your name, office phone number, state you are practicing in and email. * Yes please list my name on the ADBA website No do not list my name on the ADBA website Have there been any restrictions to any dental licenses/general anesthesia permits? If yes, please contact the ADBA Central Office at amysarno@adba.org. * Yes No Please Note The ADBA accepts only VISA and MasterCard.