Become a ppo provider

Become a PPO Provider

Thank you for your interest in choosing to be a PPO provider. There are 3 easy steps to apply:

  1. Download the forms located below
  2. Complete the forms requested. Each form is fillable so you can type right on top of the pdf.
  3. Fill out the Provider Application below and upload the completed forms.

We will send you the fee schedule once you have been credentialed. If you are interested in knowing the fees prior to credentialing, just submit your request below.

Additional items needed:

  • Wallet-size dental license
  • DEA License
  • Malpractice insurance declaration page

PPO Provider Application

Please download the necessary forms above. Once completed, you may attach and submit them under the File Upload section of the application below. Thank you.

Upload all applications necessary to enroll.
Let us know what you are interested in accomplishing