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Nominate a Dentist

By filling out this form you will nominate a dentist to become a participant in the discount dental plans offered by DentalPlans.com. We will send this provider an information packet about participating in our plans. Participation is strictly based on the individual providers willingness to do so.

Please fill the form out as completely as possible.

Your Information
First Name:
Last Name:
Email:
Phone:

Provider's Information
Provider Type:
First Name:
Last Name:
Phone:
Address 1:
Address 2:
City:
State:
ZIP:
Referred By:
	NOTE: You will be returned to the home page if your submission was successful.

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The DENTALPLANS.COM website is administered by DENTALPLANS.COM, INC., a licensed Florida Discount Medical Plan Organization, 8100 S.W. 10th Street Suite #2000, Plantation, FL 33324. Plans and Programs offered by DentalPlans.com are not health insurance policies. Plans and Programs offered by DentalPlans.com provide discounts at certain health care providers for medical services. Plans and Programs offered by DentalPlans.com do not make payments directly to the providers of medical services. The Plan or Program member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the Plan, Program or discount plan organization.

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