Dentist Information Request

Step 1: The following online or automated services may have what you need. If not, go to Step 2.

Provider Tools:

Log in to your online account to view current eligibility and benefits information, remaining maximums and deductibles, claim status and treatment history and/or enroll in direct deposit.

Automated telephone system:

Hear current eligibility and benefits information, or request faxes (there is no limit to the number of faxes you can request per call). Choose the Customer Service number for your region here: deltadentalins.com/about/contact.

Step 2 - Tell us how we can help.

What would you like to do? (Select one) Create a new contract Update my information

I'm looking for new business opportunities.

Open a new practice

Add a practice location to an existing TIN/Billing Provider

Add a treating dentist to an existing TIN/Billing Provider

Add Delta Dental PPO to an existing Delta Dental Premier contract

My current business information needs to be updated.

Change a practice address/location

Close a practice location

Change my TIN (the practice ownership is not changing)

Step 3 - Please include all the information requested below.

1. Dentist to be contracted or whose information is to be changed:

First Name

Middle Initial

Last Name

License State

License Number

Specialty

2. Practice location to be contracted or affected by a change:

Street

City

State

ZIP Code

3. Additional information about the practice location to be contracted or affected by a change:

Legal Name
of Billing Entity

TIN for IRS income reporting for Billing Entity

DBA of Billing Entity (the "Payee" on checks), if different from the legal name

4. Your contact information:

Full Name

Telephone

Thank you! You'll hear from us soon.