Dental Plan Membership

Activate Plan Now!

Online Enrollment Form

Please fill out all of the required information below to activate your dental plan membership. Once your enrollment is complete, you will receive an email and welcome package in the mail. Your package will include your member ID, account information, and details about the program.

Membership Information
Name*
First Last
Email*
Phone*
Address*
Street Address City State ZIP Code
Date of Birth*
Referral Information
Referred By
Provider Office Name
Sales Representative Name
Plan Information
Plan*
Family Members
First Name Last Name
Total
$0.00
Billing Information
Membership Plan will be active immediately.
Credit Card Number*
Credit Card Exp Month*
Credit Card Exp Year*
Credit Card CVV Code*

Usually a 3-digit number found on the back of your credit card.
- By clicking this box you are acknowledging and accepting the Dental Direct terms and understand that you will be responsible and liable for payments made against your account for enrollment in this program. This plan will automatically renew based on your selected plan. By providing your email you agree to receive marketing communications, emails, and special promotions via the contact information you provided above from Dental Direct and its partners.
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First Name	Last Name

Dental Plan Membership

Activate Plan Now!

Online Enrollment Form

Membership Information

Referral Information

Plan Information

Billing Information