DENTIST'S DOCUMENTS
before starting this form, make sure you can upload or take pictures of the following documents: unexpired driver's license/picture ID, unexpired dental license, CV(resume), malpractice insurance
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DO YOU HAVE A CORPORATION / LLC/ PLLC) THAT YOU PLAN TO USE TO GET PAID?- if you provide this info, your checks and your 1099 at the end of the year will be in that name.
*
YES
NO
CORPORATION/ LLC/PLLC NAME. IF YOU DON'T HAVE ONE, TYPE: NA
*
Your TAX ID ( TAX ID OR EIN- EMPLOYER IDENTIFICATION NUMBER- NOT YOUR SOCIAL SECURITY) number. if you don't have one, type: NA
*
UPLOAD A COPY OF YOUR DENTAL LICENSE
*
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UPLOAD A COPY OF YOUR DRIVER'S LICENSE/ PICTURE ID
*
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ENTER YOUR NPI #( NATIONAL PROVIDER ID)
*
ENTER YOUR DEA #( NOT REQUIRED, YOU CAN PUT "NA", IF YOU DON'T HAVE DEA)
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ENTER YOUR FULL SOCIAL SECURITY # ( WE KEEP YOUR INFORMATION SECURE)
*
UPLOAD A COPY OF YOUR MALPRACTICE INSURANCE DECLARATION PAGE WITH LIMITS
*
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UPLOAD YOUR COMPLETE CV (RESUME): YOU CAN UPLOAD OR TAKE A PICTURE (IF YOU DON'T HAVE THE FILE, YOU CAN SUBMIT IT LATER TO SMILECENTER215@GMAIL.COM)
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Signature( THIS WILL PRINT ON YOUR SCRIPTS)
*
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