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Provider speaking to patient.
    
/  Join Our Provider Network

Join Our Provider Network

It’s easy to become a participating provider with us. You just need to complete and submit our online application. We have prepared a checklist to make process easy to complete.

Items needed:

  • Work history the past five years
  • Education
  • Florida State Dental License
  • Certificate of Malpractice Insurance (Professional Liability Certificate) which specifies the limits of liability. (Copy of insurance invoice or binder is not acceptable)
  • Drug Enforcement Agency (If applicable)
  • Specialty Board Certificate (if applicable)
  • W9 information

Please complete all sections of the online application form in its entirety, document cannot be saved. Approximate length of time to complete is 10 – 15 minutes. Applications submitted with incomplete and/or missing information will delay the credentialing process.

To optimize your experience, please use the latest version of these browsers on your desktop or tablet: Chrome, Microsoft Edge, Firefox, or Safari.

Form will submit when all required fields are entered and all documents are signed. When this happens, the click to sign will show at bottom of form which signs the document and sends you an email to verify your address.

Ready to get started?

Launch Online Application Form