Credentialing application - Dental Network of America 2026

1. Click ‘Get Form’ to open the credentialing application in the editor.
2. Begin with the 'General Information' section. Fill in your first name, middle name, last name, and individual NPI number. Ensure you include your date of birth and gender.
3. Next, complete the 'License & Certificates' section. Enter your current state license number and its expiration date. Attach any necessary certificates as prompted.
4. Proceed to 'Dental Education'. Provide details about your dental school, graduation date, and any specialty training. Indicate if you are board certified.
5. In the 'Work History' section, list your past five years of employment. Be sure to explain any gaps greater than six months.
6. Complete the 'Confidential Questions' by answering each question with a YES or NO. Use a separate sheet for explanations if needed.
7. Finally, sign and date the form in the 'Authorization & Release' section to confirm that all information is accurate.

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