Providers Join The LIBERTY Dental Network

Please contact Provider Relations at (888) 273-2997 to receive a "master provider agreement" (only required for Owner Dentist(s) or owner)


Please complete, sign, and date an application (PDF) (required for all practicing Dentists and Associates)


Please submit current credentials (required for all practicing Dentists and Associates)
General Dentist
- Wallet size Dental License
- DEA Certificate
- Professional Liability
- W-9 form

Specialists
- Please also submit Specialty Certificate(s)


Mail forms to:
Provider Relations
3200 El Camino Real, Suite 290
Irvine, CA 92602
(888) 273-2997