An annual report for the previous year must be submitted to the Arkansas State Board of Dental Examiners by January 10 of each calendar year, which must include:

1. (1) List of all locations (street address, city, state) where mobile dental services were provided;
2. (2) Dates when services were provided;
3. (3) The number of patients treated during the year; and

4. (4) The types of services provided and quantity of each type of service:

   1. (A) Preventive. Number of patients receiving preventive services;

   2. (B) Restorative. Number of:

      1. (i) Fillings;
      2. (ii) Stainless steel crowns;
      3. (iii) Fixed prosthetics provided; and
      4. (iv) Space maintainers;

   3. (C) Surgical. Number of:

      1. (i) Teeth extracted; and
      2. (ii) Other surgical procedures performed;

   4. (D) Endodontic. Number of:

      1. (i) Root canal therapies, pulpotomies provided; or
      2. (ii) Patients referred for endodontic services;
   5. (E) Periodontal. Number of patients receiving periodontal services or referred for periodontal services;

   6. (F)

      1. (i) Prosthetics. Number of:

         1. (a) (a) Removable prostheses provided; or
         2. (b) (b) Patients referred for prosthetic services.
      2. (ii) Report may reflect “not applicable” if services are limited to children under the age of eighteen (18); and
   7. (G) Other. Number of other services provided that do not fall into the above standard categories.