*Required Fields Please complete one application per Provider 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the CREDENTIALING INFORMATION section. Select your role as either Owner or Associate, and enter your PROVIDER NAME, DATE OF BIRTH, and GENDER.
3. Complete the DENTAL PRACTICE NAME and PRIMARY PRACTICE ADDRESS fields. Ensure you provide accurate CITY, STATE, and ZIP code information.
4. Input your OFFICE PHONE # and EMERGENCY PHONE #. Fill in your FAX #, TAX IDENTIFICATION #, SOCIAL SECURITY #, and NPI numbers as required.
5. In the EDUCATION INFORMATION section, specify your SPECIALTY TYPE and indicate if you are BOARD CERTIFIED. Provide details about your DENTAL SCHOOL ATTENDED and graduation dates.
6. For LICENSURE AND PROFESSIONAL LIABILITY INFORMATION, attach copies of necessary documents like your Dental License and Malpractice Insurance Certificate. Fill in all required fields accurately.
7. Complete the 5 YEAR WORK HISTORY section with detailed employment history including any gaps in practice.
8. Answer all PROFESSIONAL QUESTIONS AND ATTESTATIONS honestly. Provide explanations for any 'YES' responses on a separate page if needed.
9. Finally, sign and date the application at the bottom before submitting it through our platform.

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