Tennessee Uniform Credentialing Form
Section 3 of 8: Professional / Medical Specialty Information
Primary Specialty:
Do you have a primary specialty to enter?
*
Yes
No
Please Select Specialty:
Please Select
Dentist, Dental Public Health
Dentist, Endodontics
Dentist, General Practice
Dentist, Oral and Maxillofacial Pathology
Dentist, Oral and Maxillofacial Radiology
Dentist, Oral and Maxillofacial Surgery
Dentist, Orthodontics and Dentofacial Orthopedics
Dentist, Pediatric Dentistry
Dentist, Periodontics
Dentist, Prosthodontics
Auto field for Specialty Code 1:
Specialty Code 1:
Are you board certified?
Yes
No
Please Select Certifying Board:
Please Select
American Board of Endodontics
American Board of Oral & Maxillofacial Pathology
American Board of Oral & Maxillofacial Radiology
American Board of Oral & Maxillofacial Surgeons
American Board of Orthodontics
American Board of Pediatric Dentistry
American Board of Periodontology
American Board of Prosthodontics
American Board of Public Health Dentistry
Boards other than ABMS/AOA
Auto field for Specialty Board Code 1:
Specialty Board Code 1:
Initial Certification Date:
/
Month
/
Day
Year
Date
Recertification Date (If Applicable):
/
Month
/
Day
Year
Date
Expiration Date (If Applicable):
/
Month
/
Day
Year
Date
Do you wish to be listed in the directory under this specialty?
Yes
No
HMO
PPO
POS
Please select one if not board certified:
I have taken exam, results pending for...
I intend to sit for an exam on...
I do not intend to take a certifying board exam...
Please Select Certifying Board:
Please Select
American Board of Endodontics
American Board of Oral & Maxillofacial Pathology
American Board of Oral & Maxillofacial Radiology
American Board of Oral & Maxillofacial Surgeons
American Board of Orthodontics
American Board of Pediatric Dentistry
American Board of Periodontology
American Board of Prosthodontics
American Board of Public Health Dentistry
Boards other than ABMS/AOA
Auto field for Specialty Board Code 2:
Specialty Board Code 2:
Please enter exam date:
/
Month
/
Day
Year
Date
Please use the space below to explain why you did not intend to take a certifying board exam.
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Tennessee Uniform Credentialing Form
Section 3 of 8: Professional / Medical Specialty Information
Secondary Specialty:
Do you have a secondary specialty to enter?
Yes
No
Please Select Specialty:
Please Select
Dentist, Dental Public Health
Dentist, Endodontics
Dentist, General Practice
Dentist, Oral and Maxillofacial Pathology
Dentist, Oral and Maxillofacial Radiology
Dentist, Oral and Maxillofacial Surgery
Dentist, Orthodontics and Dentofacial Orthopedics
Dentist, Pediatric Dentistry
Dentist, Periodontics
Dentist, Prosthodontics
Auto field for Specialty Code 2:
Specialty Code 2:
Are you board certified?
Yes
No
Please Select Certifying Board:
Please Select
American Board of Endodontics
American Board of Oral & Maxillofacial Pathology
American Board of Oral & Maxillofacial Radiology
American Board of Oral & Maxillofacial Surgeons
American Board of Orthodontics
American Board of Pediatric Dentistry
American Board of Periodontology
American Board of Prosthodontics
American Board of Public Health Dentistry
Boards other than ABMS/AOA
Auto field for Specialty Board Code 3:
Specialty Board Code 3:
Initial Certification Date:
/
Month
/
Day
Year
Date
Recertification Date (If Applicable):
/
Month
/
Day
Year
Date
Expiration Date (If Applicable):
/
Month
/
Day
Year
Date
Do you wish to be listed in the directory under this specialty?
Yes
No
HMO
PPO
POS
Please select one if not board certified:
I have taken exam, results pending for...
I intend to sit for an exam on...
I do not intend to take a certifying board exam...
Please Select Certifying Board:
Please Select
American Board of Endodontics
American Board of Oral & Maxillofacial Pathology
American Board of Oral & Maxillofacial Radiology
American Board of Oral & Maxillofacial Surgeons
American Board of Orthodontics
American Board of Pediatric Dentistry
American Board of Periodontology
American Board of Prosthodontics
American Board of Public Health Dentistry
Boards other than ABMS/AOA
Auto field for Specialty Board Code 4:
Specialty Board Code 4:
Please enter exam date:
/
Month
/
Day
Year
Date
Please use the space below to explain why you did not intend to take a certifying board exam.
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Tennessee Uniform Credentialing Form
Section 3 of 8: Professional / Medical Specialty Information
Certifications:
Do you hold the following certifications? If yes, you must provide expiration dates.
Yes
No
Expiration Date: (MM/DD/YYY)
Basic Life Support:
CPR:
Advanced Cardiac Life Support:
Neonatal Advanced Life Support:
Advanced Life Support in OB:
Advanced Trauma Life Support:
Pediatric Advanced Life Support:
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Tennessee Uniform Credentialing Form
Section 3 of 8: Professional / Medical Specialty Information
Practice Interests:
Provide additional areas of professional practice interest, activities, procedures, diagnoses or populations. You do not have to fill out all 10.
Interest 1:
Interest 2:
Interest 3:
Interest 4:
Interest 5:
Interest 6:
Interest 7:
Interest 8:
Interest 9:
Interest 10:
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Tennessee Uniform Credentialing Form
Section 3 of 8: Professional / Medical Specialty Information
Primary Credentialing Contact:
Full Name:
First Name
Middle Initial
Last Name
Address:
Street Number:
Street Name:
Suite/Building Number:
City:
State:
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code:
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Email:
example@example.com
Continue to Section 4 & 5
Should be Empty: