ADA Number Request Form

Please fill out the following form to request ADA numbers for dentists within your practice.

Requestor's First and Last Name *

Suffix

Practice Name *

Practice Address *

Dentist's First and Last Name *

Suffix

Practice Address *

Authorization *

I am authorized by the practice and dentist(s) listed above to obtain ADA number(s) for the sole purpose of assisting dentists within the practice with the credentialing process.

ADA Number Request Form

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