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DMS Dental
1-800-456-8715

DMS FACILITY PROFILE

Please fax a copy of Dental License, and  current malpractice and premise liability coverage to: 
 DMS DENTAL, Attention: New Provider Dept., (888)456-8715

 

Office Name
Lead Dentist
Dental License Number
 Please fax us a copy of License
Office Manager
Street Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
FAX
E-mail
Website address

          Please check any services offered at your office.

          Diagnostic          Preventive         Restorative            Endodontics       Orthodontics     Oral Surgery     Periodontics
         
Are emergency services available 24hrs a day?   Yes No

If Yes, what type of services (answering machine, pager, etc.)

Best Date and time to call and setup an appointment to review contract

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