Become a Dental Direct Provider — the Provider-preferred Alternative to Dental Insurance

*Dental Office Name:*Office Manager/Contact Name:

*Zip
*Telephone:Fax:

Location 1

Dental Office Name:Office Manager/Contact Name:

State:

Zip:Telephone:Fax:

Dental Office Name:Office Manager/Contact Name:

Zip:Telephone:Fax:

Check the following if applicable.

Language(s) spoken at office:

Monday:Tuesday:Wednesday:

List Name of Specialists Your Practice Refers to:

Is Hygiene done?

If yes…

number of days per week offered:

How many administrative staff members do you have?

1.

Equipment Information

check all equipment in use in office
Operatory Equipment

Office

Building Information

How long has practice been at this location?

Years

Is there parking for the practice?

Provider Information

Provider 1

*First Name:

*Last Name:

Specialty:

Degree:

*State License #:

Expiration Date:

Expiration Date:

National Provider Identifier (NPI):

*Social Security #:

Dental School:

First Name:Last Name:Specialty:

Degree:State License #:Expiration Date:

Please check the following advertising and marketing venues used for your business.

Once your application is received an on site visit will be scheduled to complete your application process and qualify you as a participating provider during normal business hours.

(On Site visit will be approximately 30min.)

Confirm by Email:Name:

or these copies can be mailed

DEA License

Acknowledgment