DENTAL PROVIDER INFORMATION REQUEST

     
 

We protect the privacy of sensitive information such as social security numbers. For more information, see our Web Privacy Notice.

 
     
  Please note the following self-service features:  
 
  • Use our downloadable forms to change your address; sell, buy, open or close an office; and/or change your Tax Identification Number (TIN).
    Update your information now.
  • Register online for our professional development and electronic claims seminars:
    Seminar schedule
 
 
If you need additional assistance, complete information below:
Dental Provider First Name Middle Initial
Dental Provider Last Name    
Dental Provider License Number    
Street Address    
     
City    
State    
ZIP Code -    
Office Phone Number ( ) -    
E-mail Address    
       
Check the item(s) below that best address your information needs:
Membership Information
I am a participating Delta Dental provider and have comments/questions about my membership:
 
I am interested in becoming a participating Delta Dental provider. Please send me a membership packet. (Be sure your address is correct above.)
I am already a Delta Dental provider and am interested in the Delta Dental PPO program. Please send me details.
(Be sure your address is correct above.)
   
Fee Allowances and Fee Filing Information
Please send me a fee revision form.(Be sure your address is correct above.)
I have comments/questions about a recently submitted fee filing:
 
   
Professional Relations
I need a Delta Dental representative to contact me about visiting my office.
My request/comments are below:
 
   
     
       
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