Are you seeing a dentist that isn’t currently in our network? Take a couple of minutes to complete the form below and we’ll take it from there. While completing the form doesn’t guarantee your dentist will join our network, it does start a valuable conversation which could lead to more savings. Prefer to mail or fax your form? Download the printer-friendly version by clicking on the printer icon.
All fields are required.
Full Name:
Your Company's Name:
Practice Name:
Dentist's Name:
Dentist's Address:
City:
State: