Phone (800) 435-2232 E-Mail info@dentaldirectoryservices.com

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Dental Provider Application

Fields marked with an * are required fields.

  • Provider Information
  • Office Information
  • Malpractice Details

Office Location(s)

Primary office address is required. You can add up to 3 additional office locations and still be a solo practice.

Primary Office Address

Add Office Hours

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Additional Office Location

Additional Office Address

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Please Enter Address 1
Please Enter Phone Number
Please Enter Valid Fax
Please Enter City
Please Select State
Please Enter Zip Code

Add Office Hours

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Additional Office Address

Delete Delete
Please Enter Address 1
Please Enter Phone Number
Please Enter Valid Fax
Please Enter City
Please Select State
Please Enter Zip Code

Add Office Hours

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Additional Office Address

Delete Delete
Please Enter Address 1
Please Enter Phone Number
Please Enter Valid Fax
Please Enter City
Please Select State
Please Enter Zip Code

Add Office Hours

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    To

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Malpractice Details

Upload individual documents or all-in-one

Option 1: Individual Document Upload

dental-license.pdf Remove

specialty license.pdf Remove

dea-registration.pdf Remove

professional-liability-coverage.pdf Remove

Option 2: All-in-one Document Upload

all-document.pdf Remove

Group or Corporate Practice

Fill out the following information and we will get back to you within 24-48 hours.
For immediate assistance call (800) 435-2232 or email info@dentaldirectoryservices.com

Download

Download An Application

If you would prefer to download a copy of the provider application, please feel free to do so. Once you are done filling it out, please email it to info@dentaldirectoryservices.com or fax it to (561) 208-1266

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