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.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CORPORATION/ LLC/PLLC NAME. IF YOU DON'T HAVE ONE, TYPE: NA
*
Your TAX ID ( TID, or EIN) number. if you don't have one, type: NA
*
DENTAL LICENSE
*
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DRIVER'S LICENSE/ PICTURE ID
*
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YOUR NPI #( NATIONAL PROVIDER ID)
*
YOUR DEA #( NOT REQUIRED, YOU CAN PUT "NA", IF YOU DON'T HAVE DEA)
*
YOUR FULL SS#
*
MALPRACTICE INSURANCE DECLARATION PAGE WITH LIMITS (IF YOU DON'T HAVE THE FILE, YOU CAN SUBMIT IT LATER TO SMILECENTER215@GMAIL.COM)
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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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Should be Empty: