Practice Interest Form
For dentists and practices seeking temporary providers
Preferred method of contact:
Provider Type Seeking:
Type of Practice:
Single-practitioner private practice
Multi-doc private practice
Multi-specialty private practice
Federally qualified health center or look-alike
Dental School or Residency Program
Region of the United States for provider to re-locate:
States for provider to practice:
Approximate date practitioner to begin employment:
Approximate employment end 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?
Should be Empty:
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