A. Ramirez v. State Board of Dentistry

IN THE COMMONWEALTH COURT OF PENNSYLVANIA
Amaris Ramirez, :
Petitioner :
:
v. : No. 144 C.D. 2023
: Argued: December 4, 2023
State Board of Dentistry, :
Respondent :
BEFORE: HONORABLE ANNE E. COVEY, Judge
HONORABLE STACY WALLACE, Judge
HONORABLE MARY HANNAH LEAVITT, Senior Judge
OPINION
BY JUDGE WALLACE FILED: January 11, 2024
Amaris Ramirez (Dr. Ramirez) petitions for review of the January 18, 2023
final adjudication and order of the State Board of Dentistry (Board), which denied
her application for licensure as a dentist in Pennsylvania. Dr. Ramirez challenges
the Board’s decision that she was not entitled to licensure by endorsement under 63
Pa.C.S. § 3111(a). Specifically, she challenges the decision that the dental licensing
requirements in the State of Florida, where she is currently licensed as a dentist, are
not “substantially equivalent” to the dental licensing requirements in Pennsylvania.
See 63 Pa.C.S. § 3111(a)(1). After careful review, we affirm.
I. Background
In 2011, Dr. Ramirez received her “Doctora en Odontología” dental degree
from Universidad Iberoamericana in the Dominican Republic. Reproduced Record
(R.R.) at 257a, 318a. Universidad Iberoamericana is not accredited by the American
Dental Association Commission on Dental Accreditation (CODA). Id. at 318a. Dr.
Ramirez practiced dentistry in the Dominican Republic for approximately two years.
Id. In 2015, she enrolled in the Advanced Education in General Dentistry (AEGD)
program at Columbia University in New York City. Id. at 319a-20a. Dr. Ramirez
completed two years in the AEGD program and received a “Certificate in Advanced
Education in General Dentistry” for each year of study. Id. at 321a-22a. Dr. Ramirez
passed multiple dental licensing examinations and, ultimately, received her Florida
dental license in 2019. Id. at 319a, 322a. She practiced as a dentist in Florida from
December 2019 until November 2020. Id. at 322a.
Dr. Ramirez filed an application for licensure in Pennsylvania on December
9, 2021. According to Dr. Ramirez, she applied because her husband “got accepted
to medical residency here,” and she had to travel back and forth between Florida and
Pennsylvania to work and spend time with her family. R.R. at 132a-33a. The Board
provisionally denied Dr. Ramirez’s application by letter dated January 20, 2022. In
its letter, the Board explained Dr. Ramirez did not meet the educational requirements
of Pennsylvania’s dental licensing regulations because, in relevant part, she did not
have a Doctor of Dental Medicine (D.M.D.) or Doctor of Dental Surgery (D.D.S.)
degree. See 49 Pa. Code § 33.102(a)(2). Moreover, the Board explained Dr.
Ramirez was not entitled to licensure by endorsement because Florida’s licensing
requirements are not substantially equivalent to Pennsylvania’s licensing
requirements. The Board reiterated that Dr. Ramirez was able to obtain a dental
license in Florida without first earning a D.M.D. or D.D.S. degree, and “[t]o meet
the ‘substantial equivalence’ standard . . . the Board requires that the licensing
jurisdiction in which an applicant is licensed requires an applicant to have a D.M.D.
or D.D.S.” R.R. at 41a-42a.
2
Dr. Ramirez appealed the Board’s decision, contending Pennsylvania does not
require applicants to have a D.M.D. or D.D.S. degree. Dr. Ramirez cited language
in 49 Pa. Code § 33.102(a)(2), which requires applicants from a nonaccredited dental
school to complete additional education at an accredited school “that will lead to the
awarding of the D.M.D or D.D.S. degree by that school.” R.R. at 45a. Dr. Ramirez
maintained she completed education that would “ostensibly . . . lead to a D.M.D. or
D.D.S. degree,” although she did not receive one. Id. at 46a-47a. In addition, Dr.
Ramirez contended she was entitled to licensure by endorsement because Florida’s
licensing requirements are substantially equivalent to the licensing requirements in
Pennsylvania. She argued the Board was requiring Florida to have equal, rather than
substantially equivalent, requirements. Dr. Ramirez asserted the Board violated her
right to due process by failing “to adequately investigate or evaluate the criteria for
licensure in Florida” and denying the application without notice or an opportunity to
be heard. Id. at 48a-49a.
The Board delegated the matter to a hearing examiner, who held a hearing via
videoconference on March 31, 2022. Dr. Ramirez testified on her own behalf and
presented the testimony of Thomas J. Boyle, D.M.D., MAGD, ABGD 1 (Dr. Boyle)
an assistant professor at Columbia University Dental School. The Commonwealth’s
counsel did not present any additional witnesses but argued in support of the Board’s
decision to deny licensure to Dr. Ramirez.
Relevant here, Dr. Boyle testified he was the former co-director of the AEGD
program at Columbia University and helped to design its curriculum. R.R. at 72a-
73a. He described the program as appropriate for dental students who already have
“some form of [p]re-[d]octorate degree, a DDS or equivalent from another country.”
1
“MAGD” stands for Master of the Academy of General Dentistry, while “ABGD” is certification
by the American Board of General Dentistry.
3
Id. at 81a. Dr. Boyle testified the AEGD program lasted one year, with the option
of a second year. Id. at 88a. If a student completed two years of the AEGD program,
he or she could then obtain dental licensure in New York State by completing a one-
year residency. Id. at 88a, 104a. Dr. Ramirez completed two years of the program
but did not pursue the residency. Id. at 89a.
Dr. Boyle’s testimony was unclear as to whether Dr. Ramirez could have
obtained a D.M.D. or D.D.S. degree through the AEGD program. Dr. Boyle initially
agreed students who completed the AEGD program did not receive a D.M.D. or
D.D.S. degree. R.R. at 81a-82a. He testified Columbia University did not offer a
program for foreign-trained dentists that awarded a D.M.D. or D.D.S. degree when
Dr. Ramirez was a student there. Id. at 84a. Dr. Boyle then testified students who
completed two years of the AEGD program and the one-year residency received an
“[e]quivalent [D.D.S.] degree.” Id. at 104a-08a.
Notably, Dr. Boyle testified Columbia University began to offer an “advanced
standing program” for foreign-trained dentists “[a]bout two years ago” that awards
a degree. R.R. at 84a. He compared the AEGD program with the advanced standing
program, opining the AEGD program “stands in advance of the advanced standing
program. . . . [I]t’s certainly above the level of the clinical training they get in an
advanced standing program.” Id. at 101a-02a.
The hearing examiner issued a proposed adjudication and order denying Dr.
Ramirez’s application on July 5, 2022. The hearing examiner focused on Florida’s
licensing requirements with respect to graduates of nonaccredited dental schools.
He reasoned Florida permits an applicant who graduated from a nonaccredited dental
school to obtain a license by completing two years in an accredited, supplemental
general dentistry program. R.R. at 333a-34a (citing Fla. Stat. § 466.006(3) (2022)).
4
In contrast, the hearing examiner observed, Pennsylvania requires an applicant who
graduated from a nonaccredited dental school to complete additional education at an
accredited school “that will lead to the awarding of the D.M.D or D.D.S. degree by
that school.” Id. at 332a-34a (quoting 49 Pa. Code § 33.102(a)(2)). The hearing
examiner determined Pennsylvania’s licensing requirements exceeded Florida’s
licensing requirements, because Pennsylvania requires applicants to obtain a D.M.D.
or D.D.S. degree, while Florida does not. Id. at 336a.
In reaching this determination, the hearing examiner specifically rejected Dr.
Ramirez’s contention that Pennsylvania law does not require applicants to obtain a
D.M.D. or D.D.S. degree, so long as they receive additional education “that will lead
to the awarding of the D.M.D. or D.D.S. degree.” R.R. at 336a (quoting 49 Pa. Code
§ 33.102(a)(2)). The hearing examiner explained this interpretation was contrary to
Section 3(c) of The Dental Law,2 which requires applicants to have “a diploma from
an approved institution or college conferring upon him or her the degree of doctor
of dental surgery [(D.D.S.)] or other established dental degree.” Id. at 332a, 336a
(quoting 63 P.S. § 122(c)). From the hearing examiner’s perspective, 49 Pa. Code
§ 33.102(a)(2) served “to confirm [T]he Dental Law’s requirement and avoid a
situation, such as the one presented in the instant case, where the applicant completed
a program that did not ‘lead to the awarding of the D.M.D. or D.D.S. degree by that
school,’ thus making the candidate statutorily ineligible for licensure.” R.R. at 336a.
The Board issued a notice of intent to review the hearing examiner’s proposed
adjudication and order, and Dr. Ramirez filed a brief on exceptions. Generally, Dr.
Ramirez repeated her contentions that Pennsylvania law does not require applicants
to obtain an D.M.D. or D.D.S. degree, and that the Board was requiring Florida to
2
Act of May 1, 1933, P.L. 216, as amended, 63 P.S. § 122(c).
5
have equal, rather than substantially equivalent, licensing requirements. She argued
the Board violated her due process rights because it failed to promulgate regulations
implementing licensure by endorsement and failed “to evaluate the statutory and
regulatory schemes of Pennsylvania and Florida” when determining whether the two
states’ requirements are substantially equivalent. R.R. at 348a, 364a-66a. The
Commonwealth filed a brief in opposition, recommending that the Board adopt the
hearing examiner’s proposed adjudication and order.
On January 18, 2023, the Board issued a final adjudication and order, adopting
the hearing examiner’s proposed adjudication, with amendments, and denying Dr.
Ramirez’s application. The Board responded to Dr. Ramirez’s exceptions, rejecting
her argument that Pennsylvania law does not require applicants to obtain a D.M.D.
or D.D.S. degree. The Board maintained it was entitled to deference regarding its
interpretation of The Dental Law. The Board explained it interpreted The Dental
Law to require a D.M.D. or D.D.S. degree from an accredited school for graduates
of nonaccredited, foreign schools and promulgated 49 Pa. Code § 33.102(a)(2) to
“confirm [T]he Dental Law’s requirement.” Final Adjudication and Order, 1/18/23,
at 4-5.3
Moreover, the Board rejected Dr. Ramirez’s contention that Florida’s dental
licensing requirements are substantially equivalent to those in Pennsylvania. The
Board reasoned that Section 3111(a)(1) limited its review “to a comparison of the
statutes, rules and regulations for the initial licensing requirements” of Pennsylvania
and Florida. Final Adjudication and Order, 1/18/23, at 12. Accordingly, the Board
could not consider whether Dr. Ramirez’s individual experiences are substantially
equivalent to Pennsylvania’s licensing requirements. The Board emphasized Florida
3
The Board’s Final Adjudication and Order does not appear in the reproduced record.
6
does not require graduates of nonaccredited, foreign schools to obtain a D.M.D. or
D.D.S. degree before being licensed. It described this as “a significant difference”
between the requirements in Florida and Pennsylvania. Id.With respect to due process, the Board explained it provided Dr. Ramirez with
notice of its decision and an opportunity to respond. Although the Board conceded
it did not promulgate regulations implementing licensure by endorsement, it noted
that it had “discussed the requirements for licensure by endorsement at several public
board meetings.” Final Adjudication and Order, 1/18/23, at 7. The Board reasoned
it retained the power to regulate licensure in the interest of public protection, and Dr.
Ramirez had no vested right to practice as a dentist.
Dr. Ramirez filed a petition for review in this Court and now raises essentially
the same arguments she raised below. Dr. Ramirez contends (1) Pennsylvania does
not require applicants who graduated from a nonaccredited dental school to obtain a
D.M.D. or D.D.S. degree, (2) Florida’s licensing requirements are substantially
equivalent to Pennsylvania’s licensing requirements, and (3) the Board violated her
right to due process.
II. Discussion
We review the Board’s decision for violations of Dr. Ramirez’s constitutional
rights, violations of agency practice and procedure, and other legal errors. 2 Pa.C.S.
§ 704. We also review whether substantial evidence supports the Board’s necessary
factual findings. Id. This Court may disturb the Board’s decision if it committed an
abuse of its discretion, exceeded its authority, or misapplied the law. Hammad v.
Bureau of Pro. & Occupational Affs., State Bd. of Veterinary Med., 124 A.3d 374,
380 n.7 (Pa. Cmwlth. 2015) (citing Nelson v. State Bd. of Veterinary Med., 863 A.2d
129, 132 n.4 (Pa. Cmwlth. 2004)).
7
A. Pennsylvania’s dental licensing requirements
We first address Dr. Ramirez’s claim that Pennsylvania law does not require
graduates from nonaccredited schools to obtain a D.M.D. or D.D.S. degree. See Dr.
Ramirez’s Br. at 10, 14-18. Section 3(c) of The Dental Law provides the Board with
the power and duty to license an applicant “who has obtained the required education,
together with a diploma from an approved institution or college conferring upon him
or her the degree of [D.D.S.] or other established dental degree.” 63 P.S. § 122(c).
The Board’s regulations provide:
(a) Dentists.
(1) Candidates for licensure as dentists shall show
compliance with [S]ection 3(c) of [The Dental Law] which
requires a diploma from an “approved institution or
college,” by submitting certification of graduation from a
dental school accredited or provisionally accredited by
[CODA].
(2) Candidates for licensure who received their
professional education outside the United States in a
nonaccredited school may satisfy the education
requirement by submitting their credentials to an
accredited or provisionally accredited school and
obtaining additional preclinical and clinical training that
will lead to the awarding of the D.M.D. or D.D.S. degree
by that school.
49 Pa. Code § 33.102(a).
Dr. Ramirez cites the language in Section 3(c) of The Dental Law, providing
for the licensure of applicants with a D.D.S. or “other established dental degree.” 63
P.S. § 122(c). Dr. Ramirez argues Section 3(c) “may reasonably be read to include
a certificate issued by a CODA-accredited institution at the level of a D.M.D. or
D.D.S. program,” such as the certificates she received from the AEGD program. Dr.
8
Ramirez’s Br. at 16-17. She maintains the Board’s contrary interpretation renders
the “other established dental degree” language superfluous and defeats the purpose
of Section 3111(a). Id. at 16-18. Similarly, Dr. Ramirez repeats her argument that
49 Pa. Code § 33.102(a)(2) allows an applicant to complete education “that will lead
to the awarding of the D.M.D. or D.D.S. degree” without actually obtaining a degree.
Dr. Ramirez’s Br. at 16, 27-28.
The Board may “adopt, promulgate, and enforce such rules and regulations as
may be deemed necessary by the [B]oard and proper to carry into effect” its powers
under The Dental Law. 63 P.S. § 122(o). The Board’s powers include an ability to
“provide for and to regulate” dental licensing in Pennsylvania and to “establish and
alter, from time to time, the standards of preliminary and professional education and
the training required for licensure to practice dentistry.” 63 P.S. § 122(a), (c).
Significantly, the Board may also “provide for the licensing of graduates of foreign
dental schools[4] in accordance with [S]ection 6.2” of The Dental Law.5 Section
6.2(b) provides:
It is the intent of the General Assembly that the provisions of this
section be construed liberally in order to ensure the establishment of
viable and accessible programs through which graduates of foreign
dental schools may obtain such further preclinical and clinical training
as shall lead to the awarding of the D.M.D. or D.D.S. degree at
accredited dental schools in this Commonwealth in order to qualify for
licensure under the provisions of this act.
63 P.S. § 125.2(b).
4
Section 2 of The Dental Law, 63 P.S. § 121, defines “foreign dental schools” as “dental schools
which have not been approved by [CODA] and which are located in countries other than the United
States or Canada.”
5
Added by Section 7 of the Act of December 20, 1985, P.L. 513, 63 P.S. § 125.2.
9
Thus, The Dental Law expressly permits the Board to promulgate regulations
governing the education necessary to become licensed as a dentist in Pennsylvania,
both for graduates of accredited schools and nonaccredited schools. See Marcellus
Shale Coal. v. Dep’t of Env’t Prot., 216 A.3d 448, 459 (Pa. Cmwlth. 2019) (en banc).
An agency may not promulgate regulations inconsistent with an enabling statute. Id.(citing Slippery Rock Area Sch. Dist. v. Unemployment Comp. Bd. of Rev., 983 A.2d
1231, 1241 (Pa. 2009)). Here, however, we discern no inconsistency between the
Board’s regulations and The Dental Law. Section 3(c) of The Dental Law addresses
the education necessary to obtain licensure as a dentist in broad terms, presumably
so the Board may exercise its authority and determine specific requirements. See 63
P.S. § 122(c). The language of 49 Pa. Code § 33.102(a)(2), meanwhile, tracks our
General Assembly’s directive in Section 6.2(b) that graduates of foreign schools may
receive licensure if they obtain additional education that will “lead to the awarding
of the D.M.D. or D.D.S. degree.” 63 P.S. § 125.2(b). Dr. Ramirez’s contention that
an applicant may receive an education “that will lead to the awarding of the D.M.D.
or D.D.S. degree” without obtaining a degree is simply an unreasonable reading of
this unambiguous statutory and regulatory language.
B. Substantial equivalence
Next, we consider Dr. Ramirez’s argument that she was entitled to licensure
by endorsement. Section 3111(a) governs licensure by endorsement for out-of-state
professionals under the Bureau of Professional and Occupational Affairs. It provides
five factors an applicant must satisfy to obtain licensure:
(a) General rule.--Notwithstanding any existing provisions related to
licensure by endorsement or licensure by reciprocity in an applicable
licensing statute, a licensing board or licensing commission shall issue
a license, certificate, registration or permit to an applicant to allow
practice in this Commonwealth if, upon application to the licensing
10
board or licensing commission, the applicant satisfies all of the
following conditions:
(1) Holds a current license, certificate, registration or
permit from another state, territory or country and the
licensing board or licensing commission determines that
state’s, territory’s or country’s requirements are
substantially equivalent to or exceed the requirements
established in this Commonwealth.
(2) Demonstrates competency in the profession or
occupation through methods determined by the licensing
board or licensing commission, including having
completed continuing education or having experience in
the profession or occupation for at least two of the five
years preceding the date of the application under this
section.
(3) Has not committed any act that constitutes grounds for
refusal, suspension or revocation of a license, certificate,
registration or permit to practice that profession or
occupation in this Commonwealth unless the licensing
board or licensing commission determines, in its
discretion, that the act should not be an impediment to the
granting of a license, certificate, registration or permit to
practice in this Commonwealth.
(4) Is in good standing and has not been disciplined by the
jurisdiction that issued the license, certificate, registration
or permit unless the licensing board or licensing
commission determines, in its discretion, that the
discipline should not be an impediment to the granting of
a license, certificate, registration or permit to practice in
this Commonwealth.
(5) Pays any fees established by the licensing board or
licensing commission by regulation.
63 Pa.C.S. § 3111(a).
The only factor at issue in this case is Section 3111(a)(1), which directs that
the licensing requirements of an applicant’s prior jurisdiction must be substantially
11
equivalent to, or exceed, the licensing requirements in Pennsylvania. Dr. Ramirez
contends the Board should have liberally construed Section 3111(a)(1) in her favor.
Dr. Ramirez’s Br. at 19-22. She contends the Board did not “conduct a meaningful
analysis and evaluation” of the two states’ requirements and should have considered
such factors as “course content, total length of programs, and overall training offered
by educational institutions to foreign-trained dentists” when determining substantial
equivalence. Id. at 18, 23, 30-38. Indeed, she argues the Board “did not undertake
any analysis or exercise any discretion, but instead . . . followed a perfunctory rule
that did not require any investigation or discretion.” Id. at 34. Dr. Ramirez compares
the requirements in Florida and Pennsylvania, emphasizing their similarities. Id. at
24-29. In addition, she cites Dr. Boyle’s testimony for the proposition that her two
years of study in the AEGD program were comparable to, or exceeded, the education
she would have received in a D.M.D. or D.D.S. program. Id. at 18-19, 30-31.
This Court recently addressed a similar dispute in Haentges v. State Board of
Dentistry (Pa. Cmwlth., No. 348 C.D. 2022, filed December 21, 2023). In that case,
a dentist from New York State, Dr. Haentges, filed an application for licensure by
endorsement in Pennsylvania. Id., slip op. at 2. The Board denied the application,
reasoning that the dental licensing requirements in New York were not substantially
equivalent to those in Pennsylvania. Id., slip op. at 6-7. Dr. Haentges completed a
one-year clinical residency after graduating from dental school to obtain a New York
dental license. Id., slip op. at 3. The Board determined Dr. Haentges’ residency was
not substantially equivalent to the clinical examination required to obtain a license
in Pennsylvania. Id., slip op. at 6-7.
On appeal, we reversed and remanded. We defined “substantially equivalent”
to mean that “the licensing requirements of an applicant’s state, territory, or country,
12
when viewed as a whole, must be equal in their essential respects, or largely equal,
to Pennsylvania’s licensing requirements.” Haentges, slip op. at 13 (footnote
omitted). The Board misinterpreted Section 3111(a)(1), we explained, by requiring
New York’s licensing requirements to be exactly the same as those in Pennsylvania.
Id., slip op. at 14-15. Further, the Board emphasized competency when determining
substantial equivalence, although the statute contained a separate competency factor
at Section 3111(a)(2) and other “safeguards” at Section 3111(a)(3)-(4). Id., slip op.
at 15. We agreed with the Board that Section 3111(a)(1) directed it to consider
licensing “requirements,” rather than Dr. Haentges’ individual experiences, but we
noted the Board looked beyond Pennsylvania’s requirements to justify its decision.
Id., slip op. at 15-16. The Board claimed to review the “plain letter of the licensing
laws” to determine substantial equivalence, but it relied primarily on information
regarding Pennsylvania’s clinical examination from outside the licensing statute and
regulations. Id., slip op. at 7, 15-16.
Even accepting that the Board did not commit an error law in its interpretation
of Section 3111(a)(1), we concluded it abused its discretion. Haentges, slip op. at
17. The Board insisted Dr. Haentges’ clinical residency, which lasted one year and
involved treating live patients, was inferior to the clinical examination required in
Pennsylvania, which lasted as little as two days and could be performed entirely on
a “manikin.” Id., slip op. at 3-5. Under the circumstances, New York’s licensing
requirements were substantially equivalent to, or exceeded, Pennsylvania’s licensing
requirements, “by any reasonable measure.”6 Id., slip op. at 17.
This case bears some similarity to Haentges. Once again, the Board appears
to have interpreted “substantially equivalent” under Section 3111(a)(1) to mean that
6
We remanded for the Board to consider Section 3111(a)(2)-(5) because it had not addressed those
factors when reaching its decision. Haentges, slip op. at 18.
13
licensing requirements of an applicant’s state, territory, or country must be exactly
the same as those in Pennsylvania. The Board’s pronouncement that a jurisdiction’s
requirements will only be substantially equivalent if they “require[] an applicant to
have a D.M.D. or D.D.S.,” R.R. at 41a-42a, refuses to consider the possibility that
another jurisdiction might have equally rigorous education requirements that do not
result in the award of either degree.
Nonetheless, a comparison of the dental licensing requirements in Florida and
Pennsylvania supports the conclusion that Florida’s requirements are not “equal in
their essential respects, or largely equal,” to Pennsylvania’s requirements. Haentges,
slip op. at 13. Florida’s licensing statute provides as follows, in relevant part:
(2) An applicant shall be entitled to take the examinations required in
this section to practice dentistry in this state if the applicant:
....
(b) 1. Is a graduate of a dental school accredited by [CODA] or its
successor entity, if any, or any other dental accrediting entity
recognized by the United States Department of Education; or
2. Is a dental student in the final year of a program at such an accredited
dental school who has completed all the coursework necessary to
prepare the student to perform the clinical and diagnostic procedures
required to pass the examinations. With respect to a dental student in
the final year of a program at a dental school, a passing score on the
examinations is valid for 365 days after the date the examinations were
completed. A dental school student who takes the licensure
examinations during the student’s final year of an approved dental
school must have graduated before being certified for licensure
pursuant to [Section] 466.011.
....
(3) If an applicant is a graduate of a dental college or school not
accredited in accordance with paragraph (2)(b) or of a dental college or
school not approved by the board, the applicant is not entitled to take
14
the examinations required in this section to practice dentistry until she
or he satisfies one of the following:
(a) Completes a program of study, as defined by the board by rule, at
an accredited American dental school and demonstrates receipt of a
D.D.S. or D.M.D. from said school; or
(b) Submits proof of having successfully completed at least 2
consecutive academic years at a full-time supplemental general
dentistry program accredited by [CODA]. This program must provide
didactic and clinical education at the level of a D.D.S. or D.M.D.
program accredited by [CODA]. For purposes of this paragraph, a
supplemental general dentistry program does not include an advanced
education program in a dental specialty.
Fla. Stat. § 466.006(2)(b), (3) (2022).
Florida requires a dentist who earned a degree from a nonaccredited school to
complete “at least 2 consecutive academic years at a full-time supplemental general
dentistry program,” which must “provide didactic and clinical education at the level
of a D.D.S. or D.M.D. program.” Fla. Stat. § 466.006(3)(b) (2022). Pennsylvania
requires a dentist who earned a degree from a nonaccredited school to complete a
D.D.S. or D.M.D. program and earn the degree he or she would have obtained by
attending an accredited school. 49 Pa. Code § 33.102(a)(2). Florida’s educational
requirements are markedly less stringent than those in Pennsylvania.
We held in Haentges, as explained above, that Section 3111(a)(1) required the
Board to determine substantial equivalence by considering the “requirements” of an
applicant’s jurisdiction, rather than his or her individual experiences. Haentges, slip
op. at 15. Despite this, it is important to recognize Dr. Ramirez’s evidence regarding
Columbia University’s AEGD program belies her argument that Florida’s licensing
requirements are substantially equivalent. Dr. Boyle testified a student in the AEGD
program could obtain an “[e]quivalent [D.D.S.] degree” by completing three years
of study. R.R. at 104a-08a. The fact Dr. Ramirez did not complete the three years
15
necessary to obtain an “[e]quivalent [D.D.S.] degree” supports the conclusion that
the two years she did complete are not equivalent to a D.M.D. or D.D.S. program.7
See id.C. Due process
Finally, Dr. Ramirez argues the Board violated her right to due process. She
contends the Board failed to comply with the General Assembly’s directive that it
promulgate regulations implementing licensure by endorsement. Dr. Ramirez’s Br.
at 34-36. Because the Board did not promulgate regulations, Dr. Ramirez contends,
she received no guidance regarding the criteria it would use when making substantial
equivalence determinations. Id. Dr. Ramirez emphasizes she has the right to pursue
her profession. Id. at 37-38. She maintains the Board deprived her of that right and
reached a decision contrary to the General Assembly’s intent of “open[ing] up the
Commonwealth to qualified professionals who are licensed in another jurisdiction
and remove administrative barriers for those out-of-state professionals to practice in
the Commonwealth.” Id. at 38.
The language found at Section 3111(a) originally appeared in the Act of July
2, 1993, P.L. 345, as amended, added by Section 1 of the Act of July 1, 2019, P.L.
292, No. 41 (Act 41), formerly 63 P.S. § 2206.1(a). The General Assembly repealed
and replaced the Act of July 2, 1993, P.L. 345, by the Act of July 1, 2020, P.L. 575,
resulting in the language’s current placement at 63 Pa.C.S. § 3111. Section 2 of Act
41 directed “each licensing board and commission” to promulgate final regulations
7
This decision is not meant to suggest the Board may deny licensure by endorsement to a Florida
dentist who earned a D.M.D. or D.D.S. degree simply because, theoretically, he or she could have
obtained a Florida dental license without one.
16
“within 18 months of the effective date of this section.” The Board concedes it did
not promulgate the necessary regulations under Act 41.8 Board’s Br. at 23.
This Court does not condone the Board’s failure to promulgate regulations in
compliance with our General Assembly’s directive. We recently rejected a similar
argument, however, in Lebron v. Public School Employees’ Retirement Board, 245
A.3d 300 (Pa. Cmwlth. 2020). We explained in that case we were unaware of “any
case law declaring that an administrative agency’s failure to promulgate regulations
creates legal rights in an individual.” Id. at 316. Despite acknowledging the Public
School Employees’ Retirement Board failed to comply with a statutory requirement
to promulgate regulations, we held it did not deprive the petitioner of his due process
rights. Id.Further, article 1, section 1 of the Pennsylvania Constitution provides that all
people “have certain inherent and indefeasible rights, among which are those of . . .
possessing and protecting property . . . and of pursuing their own happiness.” Pa.
Const. art. I, § 1. The rights to possess property and pursue happiness include within
them the right to pursue one’s chosen occupation. Ladd v. Real Est. Comm’n, 230
A.3d 1096, 1108 (Pa. 2020) (citing Nixon v. Commonwealth, 839 A.2d 277, 288 (Pa.
2003)). The right to pursue a chosen occupation is not fundamental or absolute, and
it “remains subject to the General Assembly’s police powers, which it may exercise
to preserve the public health, safety, and welfare.” Id. (citing Nixon, 839 A.2d at
287; Gambone v. Commonwealth, 101 A.2d 634, 636 (Pa. 1954)).
Dr. Ramirez relies on case law explaining, under a substantive due process
analysis, that a statute or regulation violates the right to pursue a chosen occupation
8
Section 3 of Act 41 provided it would take effect in 60 days, or on August 30, 2019, meaning the
deadline to promulgate regulations was Monday, March 1, 2021. See 1 Pa.C.S. § 1908. The Act
of July 1, 2020, P.L. 575, did not direct licensing boards or commissions to promulgate regulations.
17
if it is unreasonable, unduly oppressive, beyond the necessities of the case, or overly
broad. Dr. Ramirez’s Br. at 38 (citing Johnson v. Allegheny Intermediate Unit, 59
A.3d 10, 21 (Pa. Cmwlth. 2012) (en banc)). She does not specifically challenge any
statute or regulation, or otherwise develop this aspect of her argument. To the extent
Dr. Ramirez contends the Board’s requirement that she obtain a D.M.D. or D.D.S.
degree, as codified in 49 Pa. Code § 33.102(a)(2), violates substantive due process,
we disagree. The requirement that an applicant obtain a degree from an accredited
institution is eminently reasonable and related to the government’s valid interest in
protecting the public by ensuring dentists have adequate education and training. See
Johnson, 59 A.3d at 21; Ladd, 230 A.3d at 1108-10.
III. Conclusion
Accordingly, we conclude Dr. Ramirez is not entitled to relief, and we affirm
the Board’s January 18, 2023 final adjudication and order.
______________________________
STACY WALLACE, Judge
18
IN THE COMMONWEALTH COURT OF PENNSYLVANIA
Amaris Ramirez, :
Petitioner :
:
v. : No. 144 C.D. 2023
:
State Board of Dentistry, :
Respondent :
ORDER
AND NOW, this 11th day of January 2024, the Board of Dentistry’s January
18, 2023 final adjudication and order is AFFIRMED.
______________________________
STACY WALLACE, Judge