Please note: We may not have all the needed information on file in order to complete your re-credentialing application. Our Credentialing Department may contact you if additional information or documentation is required.
Please note: we will need a completed W9 form that includes your new Tax ID number, correct address, and a signature from your practice owner.
>>Click here to download a W9 to complete.
From the list below, select all the PPO Insurance Companies you wish to credential with:
***Please be sure that you select to credential with DNOA, which is further down this form. This is the only way for you to participate with Blue Cross and Blue Shield.
***Please be sure that you select to credential with Dentemax, which is further down this form. This is the only way for you to participate with Blue Cross and Blue Shield.
***Please be sure that you select to credential with United Concordia (UCCI), which is further down this form. This is the only way for you to participate with Blue Cross and Blue Shield.
Maverest (See Zelis)
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