Certified Clinic Director Application
Demographic Questions
Name
*
First Name
Last Name
Credentials
*
Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Email:
*
example@example.com
Phone Number
*
Please enter a valid phone number.
National Provider Identifier:
*
ADA Member Number (type N/A if not a member):
*
How did you hear about this program?
*
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Education History
What is your highest level of education?
*
Doctor of Dental Surgery (DDS)
Doctor of Dental Medicine (DMD)
List the dental school you attended, including the name of the institution, degree earned, and year of graduation:
*
Did you complete any post-graduate training (e.g., residency, fellowship, additional certifications)?
*
Yes
No
Please list program name and institution:
*
Do you hold any additional professional certifications or specialized training related to dental practice management or leadership?
*
Yes
No
Please specify (e.g. certification, year achieved, institution):
*
Are you currently licensed to practice dentistry?
*
Yes
No
State/s of Licensure:
*
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Professional Experience
What is your current Position/Title?
*
What is the name of your current practice or organization?
*
Parent Company (if applicable):
*
How many years have you been a dentist?
*
Less than 1 year
1-4 years
5-10 years
11-20 years
21+ years
Are you a full-time practicing clinician?
*
Yes
No
How many years have you been in a clinic leadership role (e.g., Clinic Director, Managing Dentist, Lead Dentist)?
*
Less than 1 year
1-2 years
3-5 years
6-10 years
10+ years
How many clinics do you currently oversee?
*
1 clinic
2-4
5-20
21+
In the practices you oversee what is the average number of dentists per location?
2 or less
3-5
5+
How many total clinics within your organization?
*
1 clinic
2-4
5-10
11-20
21+
What best describes the structure of your practice?
*
Clinic (single location)
Clinic (multi-locations)
Dental support organization (DSO) or group practice
Community Health Center or Federally Qualified Health Center (FQHC)
Academic or hospital-based practice
Other (Please specify: ______________)
What are your primary leadership responsibilities? (Check all that apply)
*
Overseeing daily clinic operations
Managing clinical staff and team dynamics
Ensuring compliance with industry regulations
Financial planning and budget management
Implementing quality improvement initiatives
Patient relations and communication strategies
Crisis management and conflict resolution
Other (Please specify: ______________)
Have you previously held leadership roles in other dental practices or healthcare organizations?
*
Yes
No
If yes, please list previous roles, organizations, and dates:
*
What are your primary challenges in your current leadership role (select all that apply)?
*
Team management and staff retention
Financial oversight and budgeting
Compliance and regulatory requirements
Operational efficiency and workflow optimization
Patient engagement and satisfaction
Professional growth
Work/Life balance
Other
Please specify:
*
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Personal Statement & Program Goals
Briefly describe your current role and responsibilities (200 words max):
*
What do you aim to achieve through participation in the Certified Clinic Director Program? (200 words max):
*
Are there certain areas of expertise that you can bring to a collaborative learning environment? (200 words max)
*
Share your leadership vision/philosophy? (250 words max)
*
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References
Two references are required and you will be asked to submit letters of recommendation
Reference One Name:
*
First Name
Last Name
Email:
*
example@example.com
Title:
*
Company:
*
Reference Two Name:
*
First Name
Last Name
Email
*
example@example.com
Title:
*
Company:
*
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Attestation
Important Dates
Please review the dates below that require mandatory attendance
Will you be able to fulfill the commitment to participate in the dates outlined for the program?
*
Yes
No
If no, please list which dates you cannot attend:
*
I understand and agree that should my application be accepted that I am responsible for all travel and hotel fees to attend the In-Person Kick-Off in Chicago, IL on September 19, 2025:
Yes
No
Do you have the support of your employer for the time required to participate in this program?
*
Yes
No
Please upload your CV:
*
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