Your Credentialing Checklist
This checklist is your lifeline to credentialing. We are unable to proceed until you have completed this checklist. You can save this list and come back to it as you are finding your documents and numbers. To do so, click "Save" at the bottom of the form.
Name
*
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Social Security Number
*
xxx-xx-xxxx
Birth Date
-
Month
-
Day
Year
Date
As you upload these files, check them off here. Use the File Upload option just below.
W-9 Form
Professional Liability Insurance Face Sheet
All active State Dental Licenses
DEA
CDS
Specialty Certificate(s) or License(s)
CPR
BLS
General Anesthesia Certificate/License
Curriculum Vitae
MA Provider ID (if applicable)
Medicare Provider ID (if applicable)
File Upload
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of
NPI #
*
CAQH #
Languages Spoke
Enter languages separated by comma
Save
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