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Become a provider | office information

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Provider Application Instructions TO SUBMIT ONLINE: Please complete the Office Information and Dentist Information sections.
Check off the Provider Agreement and upload your state license(s), DEA certificate, and malpractice
insurance documents when requested. TO SUBMIT BY FAX OR EMAIL: Please include the following materials: a. Completed Office Infomation and Dentist Information sections
b. Signed Provider Agreement
c. Current copy of state license(s)
d. Current copy of DEA certificate
e. Current copy of malpractice insurance Fax to: 212.688.9708
Mail to: DentalSave, Corporate Headquarters
845 Third Avenue, 20th fl, New York, NY 10022 Please allow two weeks for processing. Your listing will appear on our website (www.DentalSave.com) within
one week after processing is completed. It will be published in the next printing of our Directory of Dentists.

Office Information

Practice Name *  
Address 1 *  
Address 2
City *  
State *
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Zip Code *  
Phone * - -      
Fax - -
Emergency Phone - -
Email Address
URL (website)
TIN Number (no dash) *  
NPI Number (no dash) *  
Office Mgr First
Office Mgr Last
Office Mgr Phone - - ext
Office Features
Specialties
Languages spoken other than English
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Handicap Access
Hygienist
Lab on Premises
Medicaid Accepted
Financing
Willing to treat children
Hours of operation
Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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Sunday
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Current fees charged
Code Description Fee
D0150 Comprehensive oral evaluation
D1110 Prophylaxis - Adult
D0210 Intraoral - Complete Series
D4341 Periodontal Scaling
D2392 Composite - Posterior Two Surfaces
D2750 Crown
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