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