Provider Enrollment Form

Please briefly explain your license request below

Business Name

Contact Number

Servicing members for more than one state? Yes

Note: Colorado dental providers enrolling in a Medicaid plan need to enroll with the State of Colorado

Provider’s Individual NPI

Tax ID Number(s)

CAQH ID

Participating Network Types (select all that apply) Medicaid Adult Medicaid Child Special Needs CHIP Medicare Advantage Commercial Marketplace

For California Residents
Privacy Policy and Notice for California Residents

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PREVENTISTRY PULSE

The newsletter designed for anyone who wants to improve oral health for themselves, their families, customers or communities.