course attendance verification

Northlake Dental Association

Post Office Box 8925 Mandeville, LA 70470 www.ndassn.org P: (985) 807-4503 F: (985) 875-9000 E: [email protected]

COURSE ATTENDANCE VERIFICATION Participant’s Name: Anna Aguilard Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director

Approved PACE Program Provider FAGD/MAGD Credit (1/27/2014) to (1/31/2017) Provider AGD ID #219143 Keep this form for your records. AGD Members: Northlake Dental Association will submit attendance verification to the AGD on your behalf.



COURSE ATTENDANCE VERIFICATION Participant’s Name: Dr. Butch Polito Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Terri Prokop Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Catherine A. Hebert, DDS Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Steven Carpenter Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Carolyn Jennings Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Crystal Aranyosi Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Stephen Baehr Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Denise Bales Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Dr. Kevin Sullivan Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Dr. Earle Brown Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Nikki Hughes Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Glen Corcoran DDS Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: J. Ellis Bernard, DDS Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Kathleen G. Engel DDS Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Lisa Pellegrini Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Marija G. LaSalle, D.D.S. Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Mindy Hickey Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Dr Paul Anzalone Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Raquel Valle Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Terry Truxillo D.D.S. Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Dr. Warren W. Wood Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Dr. Randy Mayer Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Evangelyn Meyer Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Michael Mesa Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Tony Paternostro Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Sheridan Supple-Puls Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director




COURSE ATTENDANCE VERIFICATION Participant’s Name: Lain Gay Participant AGD ID#: Course Title: "Simple & Profitable Implant Treatment: The 'TEAM' Approach" Co-Sponsored by Dentsply Implants & Mesa Dental Arts Speaker: Alan Scott Douglas, DDS Educational Method: Lecture CDE Hours: 7 Course Date: Friday, February 21st, 2014 Location: Tchefuncte Country Club – Covington, LA Verification Code: 22114 Authorized NDA Representative: Kathleen Brown, Executive Director


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