Providers Join The LIBERTY Dental Network

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

Specialists
- Please also submit Specialty Certificate(s)


Mail forms to:
Provider Relations
3200 El Camino Real, Suite 290
Irvine, CA 92602
(888) 703-6999