We are delighted that you have decided to join us in our pursuit to create a healthier nation.

Once you submit this form along with your payment, you can expect to receive an email from us. The email will contain NEXT STEPS to get you on-boarded, with links, examples and access to some materials you can brand with your practice info.

Provider Application

National Dental Association

Practice Name

Provider Last Name

Provider First Name

Area of Care

FQHC / CHC

GP-Dental

GP-Medical

Other

Primary Office Address

Street Address

City

State

Zip code

County

Email

Phone

Number of additional offices

Main Office Contact Name:

How many patients do you see per month?

Types of care finance accepted:

HMO

Commercial indemnity

Medicaid

Discount plan

PPO

Self-insured

Medicare/Medicare Advantage

No insurance accepted

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