provider packet request form · 2019. 7. 1. · *important note: only requests to join our network...
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*Important Note: Only requests to join our network are processed through the email addresses above. If your request does not relate
to a provider joining our network or a packet request, please contact our Provider Services Team at 1-800-822-5353 for further
assistance. V6/2019
Provider Packet Request Form
Please indicate in the email subject line - Packet Request [State] [County].
Dentist First Name: Dentist Last Name: Associate/Owner: NPI: Specialty:
Email Address: Contact Name:
Practice Name: Phone Number:
Address: County:
City: State: ZIP Code:
Mailing Address: (If Different from Practice Address)
City: State: ZIP Code:
Regional Map
Please check the dental network(s) that you wish to join:
PPO (Commercial) Medicare Medicaid DHMO/Direct Compensation
Are the Dentists above being added to an existing participating location? Yes No Is this a new practice location? Yes No
Please complete all fields and email the completed form to the email address* that applies to your state and region: (Refer to the Regional Map below as your guide.)
Central Region: [email protected] Southeast Region: [email protected]
Northeast Region: [email protected] West Region: [email protected]
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