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Dental claim form 2004

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PROVIDER TAXONOMY CODES 58. Treating Provider Specialty Enter the code that indicates the type of dental professional who delivered the treatment. Key extracts from that section of CDT-2005 follow GENERAL INSTRUCTIONS A. The form is designed so that the Primary Payer s primary insurance company name and address Item 3 are visible in a standard 10 window envelope. Please fold the form using the tick-marks printed in the margin* B. In the upper-right of the form a blank space is provided for the ...

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