DENTAL PROVIDER SERVICE REQUEST

     
 

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Required Information to Access Records Regarding Your Request:
         
Select type of provider:
DeltaCare USA dental providers
  Facility Name Facility Number
  Street Address Contact Name
  City Contact Phone ( ) -
  State    
All other dental providers      
  Dental Provider First Name Dental Provider License Number Numbers only; no letters or special characters
  Dental Provider Last Name Dental Provider Taxpayer Identification Number (TIN) Numbers only; no letters or special characters
  Street Address Contact Name
  City Contact Phone ( ) -
  State    
         
Please select all that apply:
Forgot user ID
Forgot password
Information does not match
Authorization code not received or does not work
 
Explanation of request:
 
Please provide a working e-mail address so that we may respond to your office:
E-mail address
         
         
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