Dentist Information
ID
CasePriority
Please Select
High
CaseType
Please Select
Network Questions
RecordTypeID
CaseStatus
Please Select
New
CaseReason
CaseOrigin
Please Select
Becoming a network provider
OwnerId
Dentist Name
*
First Name
Last Name
Clinic Name
*
Dental Office Phone Number
*
Please enter a valid phone number.
Have questions? Call our Provider Relations team at 800-448-3815
Requester Information
State where clinic is located
*
Please Select
Minnesota
North Dakota
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Is this question regarding
General Inquiry
Joining a Network
Status of credentialing
Adding a new dentist location
DOT Registration or DOT registration question
Additional Comments
SF Description
Submit
Should be Empty: