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Provider Interest Form - Group Practice

Thank you for your interest in becoming a LIBERTY Dental Plan network provider. A Professional Relations team member will contact you shortly to discuss our various benefit plans and provider contracting agreements.

The submission of the document listed below does not guarantee acceptance into the LIBERTY network.  Providers are reviewed based on current network needs, federal and state regulations and on an individual basis, according to credentialing requirements.

If you have any questions regarding the credentialing and/or contracting process, please contact our Professional Relations department at (888) 700-0643.

Please note: Items marked with a (*) are required!

* Organization Name
* Corporate Address
* City
* State
* Zip Code
* Total number of offices
* Primary Contact Name
* Phone
Fax number
* Email Address
* Group Tax ID #
* Organizational NPI #
Specialty type(s) provided by group: (Choose all that apply)!

Please list other dental plans you currently participate with:
Do you have a Medicaid Number?
If 'YES", please provide #
Are you an: (Choose all that apply).
Questions or Comments:

Please only click Submit once