Zelis Dental Provider Contract Data Sheet

Tennessee Credentialing Form

Dental Provider Contract Data Sheet
Dentist Name:*

First NameMiddle InitialLast NameSuffix
Degree:*
Specialty:*

GeneralEndodonticsOral SurgeryPediatric DentistPeriodonticsProsthodonticsOrthodontics
Tax ID Number:*
Tax ID must match what is on Form W-9
Please upload Form W-9: Important: Practice Name on Form W-9 must match business name on income tax return.*

You can access Form W-9 from https://www.irs.gov/pub/irs-pdf/fw9.pdf
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Provider Individual NPI Number (Type 1):*
Do you have a Group NPI Number (Type 2)?*

YesNo
Group NPI Number (Type 2):
Practice Name (to be listed in directory):*
Primary Practice Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Practice Phone Number:*
Please enter a valid phone number.
Primary Practice Fax Number:
Please enter a valid phone number.
How many locations for this provider?*
Is billing address different from practice address?*

YesNo
Billing Address:

Street Address

Street Address Line 2

CityState

Zip Code
Billing Phone Number:
Please enter a valid phone number.
Billing Fax Number:
Please enter a valid phone number.
Credentialing Contact: Who should we contact for credentialing questions or issues?*

First NameLast Name
Credentialing Contact Phone Number:*
Please enter a valid phone number.
Credentialing Contact Fax Number:
Please enter a valid phone number.
Credentialing Contact Email:*
example@example.com
Please upload current Dental License*

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Please upload specialty certificate, if applicable:

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Should be Empty:

Tennessee Credentialing Form