Sample Dental Provider Contract Data Sheet Dentist Name: First Name Middle Name Last Name Suffix Degree: Please Select DMD DDS Specialty: General Endodontics Oral Surgery Pediatric Dentist Periodontics Prosthodontics Orthodontics Tax ID Number: Tax ID must match what is on Form W-9 Please upload Form W-9: Important: Practice Name on Form W-9 must match business name on income tax return. Browse Files Drag and drop files here Choose a file You can access Form W-9 from https://www.irs.gov/pub/irs-pdf/fw9.pdf Cancel of Provider Individual NPI Number (Type 1): Practice Name (to be listed in directory): Primary Practice Address: Street Address Street Address Line 2 City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Primary Practice Phone Number: Please enter a valid phone number. Primary Practice Fax Number: Please enter a valid phone number. How many locations for this provider? Is billing address different from practice address? Yes No Billing Address: Street Address Street Address Line 2 City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Billing Phone Number: Please enter a valid phone number. Billing Fax Number: Please enter a valid phone number. Credentialing Contact: Who should we contact for credentialing questions or issues? First Name Last Name Credentialing Contact Phone Number: Please enter a valid phone number. Credentialing Contact Fax Number: Please enter a valid phone number. Credentialing Contact Email: example@example.com Please upload current Dental License Browse Files Drag and drop files here Choose a file Cancel of Please upload specialty certificate, if applicable: Browse Files Drag and drop files here Choose a file Cancel of Continue to Maryland Credentialing Application Should be Empty: