To become a LIBERTY Dental Network Provider please follow and complete the steps below.

		Please complete, sign and date a master provider agreement (only required for Owner Dentist(s) or owner) [General] [Associate] [Endo] [Ortho] [Oral] [Pedo] [Perio]
		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 Specialist - Please also submit Specialty Certificate(s)
		Mail forms to: Provider Relations 3200 El Camino Real, Suite 290 Irvine, CA 92602 (888) 703-6999