Business Name *
Contact Number
Servicing members for more than one state
If you do not find your state, please go to click on your state, then Dentist Page
Servicing Members from following State(s) *
Provider’s Individual NPI *
Tax ID Number(s)
Currently enrolled and have a current application on file with CAQH *
Practice Type *
Provider's Primary Specialty *
Participating Network Types (select all that apply)*

Office Location Counties (select all that apply)