Home Page
Contact Us
Your Team
Community Support
"
*
" indicates required fields
Name
*
First
Last
Email
*
How many locations do you have under your TIN?
*
One
Two or more
Are you looking for services in regards to a practice purchase?
*
Yes
No
Do you participate with 3 or more PPOs currently?
*
Yes
No
Are you a past client?
*
Yes
No
Which type(s) of providers are located at your location?
General Dentists
Endodontists
Oral Surgeons
Orthodontists
Pedodontists
Prosthodontists
How many General Dentists are currently contracted with PPOs at this location?
*
One
Two
Three(+)
How many Endodontists are currently contracted with PPOs at this location?
*
One
Two
Three(+)
How many Oral Surgeons are currently contracted with PPOs at this location?
*
One
Two
Three(+)
How many Orthodontists are currently contracted with PPOs at this location?
*
One
Two
Three(+)
How many Pedodontists are currently contracted with PPOs at this location?
*
One
Two
Three(+)
How many Prosthodontists are currently contracted with PPOs at this location?
*
One
Two
Three(+)
GP_COUNT
ENDO_COUNT
OS_COUNT
ORTHO_COUNT
PEDO_COUNT
PROSTHO_COUNT
SPEC_DISC_VALUE
Disq-MultipleLocations
Disq-PracticePurchase
Disq-NumberDoctors
Disqualified
