Application

Step 1: Practice Information
Please enter your practice legal name.
Please enter your practice address.
Please enter your practice address.
Please enter your practice city.
Please select your practice state.
Please enter your practice ZIP code.
Please enter your practice office phone number.
Please enter your practice email address.
Please enter your practice tax identification number.
Please enter your social security number.
Please enter your practice office manager's name.
Please select who we should issue checks to.
Please select your practice type.
Please enter the mobile number that you wish to receive text messages to alert you when being paid.
Please enter your practice NPI type 1.
Please enter your practice NPI type 2.
Please enter your practice dental license number.
Please enter your practice DEA certificate number.
Please select your date of birth.
Please select your practice organization structure.