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Delta address change form

Delta address change form 2026

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The document is a Notice of Address Change form for contracted Delta Dental practice owners to report changes in their practice location and mailing address. It outlines the process for updating the address, including notification timelines, implications for fee schedules based on geographic regions, and instructions for submitting the form. The document also clarifies that it is not intended for adding new dentists or locations.

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Click ‘Get Form’ to open the delta address change form in the editor.
Begin by filling out the 'Billing Dentist or Dental Entity Information' section. Enter your practice owner’s name, legal business name, Taxpayer Identification Number (TIN), and Business NPI (Type 2).
In the 'Former Address' section, provide your previous practice location and mailing address. Include telephone numbers for both locations.
Next, move to the 'New Address' section. Input your new practice location and mailing address, along with updated telephone and fax numbers.
Complete the certification statement at the bottom of the form by signing and dating it. Ensure all information is accurate before submission.
Finally, return the completed form via email or mail to your local Delta Dental office as specified in the instructions.

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