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Nominate a Dentist

Nominate a Dentist to the Connection Dental® Network

If the dentist of your choice is not listed in the directory, you may complete this form to nominate the dentist to participate in the Connection Dental Network. An application packet and information about the Connection Dental Network will be sent to eligible providers. If your dentist chooses to join the network, the normal time frame to complete the nomination process is approximately 60 days.

Nominate a Dentist

    All fields marked with an '*' are required to complete this form.
       
    Dentist Information
     
    Name *  
    Address *  
       
    City *     State *  
    Zip Code  
    Phone  
    Specialty  


    Member Information
     
    Name  
    Address  
       
    City     State  
    Zip Code  
    Phone  
    Email Address  
    Employer *  
    Insurance Company *  


    Comments:



    To speak to a Client Relations Specialist about your nomination, please call (877) 277-6872.

    Thank you for helping to grow the Connection Dental Network.