(b) To obtain or renew a fictitious name permit, the dentist, association, partnership, group, or dental corporation shall apply to the board on an application form prescribed by the board and provide all of the following information:

1. (1) The names, license numbers, and contact information for each applicant engaging in practice under the fictitious name.
2. (2) The address of the place or establishment, or the portion thereof, where the applicant or applicants practice under the fictitious name.
3. (3) Evidence that the place or establishment, or the portion thereof, identified in paragraph (2) is owned or leased by the applicant or applicants, and the practice conducted at the place or establishment, or portion thereof, is wholly owned and entirely controlled by the applicant or applicants.
4. (4) The fictitious name under which the applicant or applicants propose to engage in dental practice that contains at least one of the following designations: “dental group,” “dental practice,” “dental office,” or “dental corporation,” as applicable pursuant to Section 1804, and is in conformity with Section 651 and subdivisions (i) and (l) of Section 1680.