DDS - JOIN

Dental Provider Application

First Name*

Last Name*

Phone#*

Email Address*

Specialization*

NPI#*

License#*

License State*

DEA#*

School Name*

Year Graduated*

Tel: (800) 435-2232
Fax: (516) 213-1143
Monday-Friday, 9am-7pm ET.

info@dentaldirectoryservices.com

160 Eileen Way,
Syosset, NY 11791

A Registered Trademark of United Health Programs of America, Inc.