What a DSO can and can't do

A dental support organization (DSO) may provide any non-clinical service a dental practice needs: space, equipment, supplies, technology, non-clinical staff, marketing, finance, and billing support. It may not, in states with a corporate practice of dentistry (CPOD) doctrine, employ dentists to practice, own the patient records, control clinical staffing, set treatment plans or fees, direct coding, or take a fee that amounts to profit-sharing. Several dental statutes and board rules identify specific functions a non-dentist may or may not control. Kansas, Nevada, Washington, Illinois, Indiana, and Kentucky provide express restrictions, while Florida’s board identifies permitted practice-management services. These texts offer a useful starting point, but the details and surrounding law still vary by state.

​

The two columns

​

The statutes wrote the columns

The prohibited column is not a lawyer’s abstraction. It closely tracks lists that appear, nearly verbatim, in state law:

• Kansas: K.S.A. 65-1471 voids an agreement giving a non-dentist specified control over dental treatment, patient acceptance, professional services, patient records, dental equipment and materials, or clinical staff. It includes exceptions for certain equipment arrangements and lists administrative services that may be performed “under the direction or with the consent or approval of a licensed dentist.”¹
• Florida: Board Rule 64B5-17.013 permits contracts for enumerated “practice management services.” The list covers office space and equipment suitability, staffing, regulatory compliance, productivity methods, inventory and supplies, information systems, marketing, site selection and office design, and several financial services.²
• Washington: RCW 18.32.677 identifies ten interference categories involving patient time and volume, treatment, equipment and materials, laboratories and supplies, professional training, referrals, record access, refunds, compliant advertising, and patient communications. RCW 18.32.675 separately defines permitted ownership and lease relationships and excludes dental records from its listed assets.³
• Nevada: NRS 631.215(2)(i) and 631.3455 permit support goods and services subject to restrictions. Among other things, the provider may not receive “payments based on a percentage or share of revenues or profits,” control clinical practice, own clinical records, or employ the listed licensed personnel, including dentists, hygienists, dental therapists, and expanded-function assistants.⁴
• Illinois: 225 ILCS 25/38.1 bars a dentist from being employed by a non-dentist and from allowing a non-dentist to “direct, control, or interfere with” clinical judgment. The statute identifies treatment selection, referrals, record content, refund policies, clinical advertising content, and final hiring decisions for assistants and hygienists.⁵
• Indiana: IC 25-14-1-23(a)(10)–(13) treats being a dentist’s employer and specified contractual controls as the practice of dentistry. The covered controls include treatment, referrals, records, refunds, advertising, and clinical personnel. The statute separately permits “advice or assistance” on those topics. Unlicensed practice is a Level 6 felony.⁶
• Kentucky: KRS 313.075(2), effective April 2026, prohibits a non-licensee from controlling clinical decisions, diagnosis or treatment planning, patient records, supervision of licensed dental personnel, or a dentist’s professional judgment. Kentucky otherwise permits a lay-ownership path under the same statutory section.⁷
• California: SB 351, effective January 2026, expressly applies to dental practices. A covered private equity group or hedge fund may not interfere with treatment options or referrals, control patient volume or provider schedules, or exercise specified control over records, clinically based hiring and firing, payer contracting, coding and billing, or selection of dental equipment and supplies.⁸

Settlements add further detail. The May 2026 California Aspen Dental settlement enjoined the DSO from replacing practice owners, owning practice real estate, taking revenue-based fees, setting clinical-staff compensation, directing scheduling, paying sales incentives to clinical staff, and imposing noncompetes on clinical staff.⁹ Function-specific lists help operators apply a general prohibition on interference to day-to-day decisions.

​

Distinguishing support from control

Billing and payer contracting appear in both columns. Whether the DSO supports or controls those functions depends on its actual authority and workflow. Many DSO-PC arrangements operate near this boundary: Coding requires a careful division of responsibility. A CDT code describes what was done and why. The distinction between a D3220 pulpotomy and a D3110 pulp cap, for example, depends on clinical facts. A DSO may provide trained billers, software, and workflow support where permitted, while the MSA and actual process should preserve the coding authority required by state law and payer rules. Dentists need a meaningful way to correct or reject a coding change. See Run a CPOD self-audit.

​

The gray zone, honestly described

Several recurring questions depend on the state text and actual operating facts: Scheduling templates. A DSO may provide the scheduling system and staff where the state permits it. A template that dictates eight hygiene visits and ninety minutes of doctor exam time per day can also function as a patient-time or volume quota. Washington expressly addresses patient time and volume, and California’s SB 351 reaches “provider schedules.” A conservative approach is for the PC to approve clinical appointment-length and volume standards, with the DSO implementing the template and reporting results. Treatment-plan presentation. Dental groups often use nonclinical treatment coordinators to explain cost and financing after the dentist diagnoses and recommends care. The risk changes when a coordinator or compensation plan pressures patients toward higher-production options. The California Aspen settlement restricted sales incentives for clinical staff of the settling parties, including hygienist payments tied to aligner sales.⁹ Collections and refunds. Mostly administrative, but refunds are on Washington’s enumerated list and Illinois’s, because a refund is often an implicit judgment about whether care was adequate. Best practice is PC approval of the policy, DSO execution of it. Membership plan pricing. An in-house membership plan often uses the practice’s fee schedule. In states such as Mississippi, fee-setting authority belongs to the dentist. Document the PC’s approval of plan pricing where required. Marketing. A DSO may provide marketing services, but the content must comply with state rules about who is presented as the provider. The California AG alleged that Aspen advertising obscured practice ownership, and the resulting settlement requires the settling parties to identify practice owners in ads.⁹ Name the practice and its owners when state law requires it. Recruiting. The DSO can commonly source and screen candidates. The state-law-authorized employer and licensed clinical decision-maker should retain every hiring, supervision, scope, and termination decision the dental rules reserve to them, with actual practice matching the documents. AI tooling. An AI tool that suggests CDT codes for review presents different control questions from one that assigns codes without meaningful clinician review. California’s SB 351 expressly identifies coding and billing decisions among the restricted controls for covered entities. See LLMs, zero data retention, and HIPAA.

​

What varies by state

The columns above are most useful in states with restrictive ownership or control rules. States such as Arizona, New Mexico, Utah, and Wisconsin use different ownership paths, but authorized lay ownership does not eliminate every clinical-control restriction. Kentucky permits lay ownership while protecting clinical judgment, and Wisconsin contemplates lay employers while restricting patient and procedure quotas in employment contracts.⁷ Three considerations argue for building to the strict standard anyway:

1. You will expand. Dentistry’s growth channel is acquisition across state lines, and rebuilding governance for state four is harder than building it right at state one.
2. Recent laws add more specific controls. California and Kentucky enacted clinical-control provisions effective in 2026. The Aspen settlements also addressed succession rights, revenue-based fees, and real-estate arrangements for the settling parties.^{8 9}
3. Diligence applies the strict standard. Acquirers and lenders underwrite the worst-case jurisdiction. See DSO enforcement and risk.

State-by-state pinpoints live at DSO laws by state.

​

The five bright lines

If you remember nothing else:

1. The PC employs the dentists and hygienists.
2. The PC owns the patient records.
3. The PC controls its own bank account and receipts.
4. The dentist or professional entity retains the clinical decisions required by state law, including diagnosis, treatment planning, materials, laboratories, referrals, and coding where applicable.
5. The fee pays for documented services under a lawful formula. Review any DSO-paid clinical incentive under state control, fee-splitting, payer, and fraud-and-abuse rules.

Hold those five and most gray-zone questions resolve themselves.

​

Sources

1. K.S.A. 65-1471 (dental services agreements; limitations). Kansas Revisor.
2. Fla. Admin. Code R. 64B5-17.013 (Proprietorship by Nondentists). Florida Administrative Code.
3. RCW 18.32.677 (text); RCW 18.32.675 (text) (2017 c 320).
4. NRS 631.215(2)(i), 631.3455. NRS ch. 631.
5. 225 ILCS 25/38.1 (prohibition against interference by non-dentists). ILGA.
6. IC 25-14-1-23(a)(10)–(13). FindLaw.
7. KRS 313.075 (eff. Apr. 13, 2026). Kentucky Legislature. Wisconsin quota ban: Wis. Stat. § 447.06(1g).
8. Cal. S.B. 351 (2025), Health & Safety Code §§ 1190–1191, effective January 1, 2026; the operative text runs to “physician or dental practice” throughout. Summary: Benesch, California Enacts SB 351.
9. California AG, settlement with Aspen Dental over corporate practice (May 7, 2026); DLA Piper, CPOM enforcement: new pressure points (July 2026).
10. Miss. State Bd. of Dental Examiners, Regulation 55. Board PDF.