LDA/LSU Alumni Association - Mentor Registration
Full Name
*
First Name
Last Name
Email
*
Office Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Telephone Number
*
-
Area Code
Phone Number
Mobile Telephone Number
*
-
Area Code
Phone Number
Preferred contact telephone number?
*
Office
Mobile
Component
*
Acadiana
Bayou
Central
Greater Baton Rouge
NODA
Northeast
Northlake
Southwest
Northwest
How many years have you been in practice?
*
Are you willing to mentor more than one student?
*
Yes
No
Please check all that apply to your practice or area of expertise:
*
Buying a Practice
Dentist Employer/Employee Contracts
Starting a Practice
Managed Care Programs
Associateships
Group Practice
Solo Practice
Endodontics
Orthodontics
General Practice
Pediatric Dentistry
Military/Federal Service Dentistry
Periodontics
Oral & Maxillofacial Surgery
Oral Pathology
Prosthodontics
Public Health
Please list any special requests (e.g., male/female, want/don't want to specialize, from certain area of state). We will do our best to meet your requests.
*
Activities, interests & hobbies OUTSIDE of practicing dentistry:
*
For questions, contact the LDA at (225) 926-1986.
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