Practice Interest Form
For dentists and practices seeking temporary providers
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Preferred method of contact:
Please Select
Phone call
Text
Email
Provider Type Seeking:
Please Select
General Dentist
Endodontist
Oral Pathologist
Oral Radiologist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Dental Anesthesiologist
Type of Practice:
Please Select
Single-practitioner private practice
Multi-doc private practice
Multi-specialty private practice
Federally qualified health center or look-alike
Dental School or Residency Program
DSO
Other
Region of the United States for provider to re-locate:
East Coast
Northeast
Southeast
Midwest
Southwest
West Coast
Hawai'i
Alaska
Other
States for provider to practice:
Approximate date practitioner to begin employment:
-
Month
-
Day
Year
Date
Approximate employment end date:
-
Month
-
Day
Year
Date
List insurances provider must credential with for your opportunity. Please include any Medicaid or state insurances your office participates in.
Additional information about your practice or opportunity. Please provide hours and days of the week requested. Please also add any specific responsibilities other than patient care (sedation, staff management, hospital call, etc).
List specific attributes you are looking for in a provider (i.e. new grad, length of experience or employment, energetic vs calm and collected, etc).
Is there a possibility this opportunity could turn into a long-term or ownership opportunity?
Save
Submit
Should be Empty: