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Provider Interest Form - Solo Practitioner

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!

 

* Dentist Name
* Primary Office Name
Contact Person
* Address
* City
* State
* Zip Code
* Number of locations
* Phone Number
* Email Address
* Tax ID #
* Individual NPI #
* Languages Spoken
Specialty type(s): Check all that apply!




Please list other health plans you currently participate with:
* Do you have a Medicaid Number?
If 'YES", please provide #

Please only click Submit once