Business Name *	Business Name * Business Name *
Contact Number	Contact Number Contact Number
Servicing members for more than one state	Servicing members for more than one state Servicing members for more than one state Select
If you do not find your state, please go to www.dentaquest.com/dentists click on your state, then Dentist Page	If you do not find your state, please go to www.dentaquest.com/dentists click on your state, then Dentist Page If you do not find your state, please go to www.dentaquest.com/dentists click on your state, then Dentist Page
Servicing Members from following State(s) *	Select Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Virginia Washington West Virginia Wisconsin Servicing Members from following State(s) * Servicing Members from following State(s) *
Provider’s Individual NPI *	Provider’s Individual NPI * Provider’s Individual NPI *
Tax ID Number(s)	Tax ID Number(s) Tax ID Number(s)
Currently enrolled and have a current application on file with CAQH *	Select Yes No Currently enrolled and have a current application on file with CAQH * Currently enrolled and have a current application on file with CAQH *
CAQH ID	CAQH ID CAQH ID
Practice Type *	Select FQHC Group Practice Sole Practitioner Tribal Practice Type * Practice Type *
Provider's Primary Specialty *	Select Endodontist Oral Surgeon General Dentist Pediatric Dentist Periodontist Prosthodontist Denturist Orthodontist Dental Hygienist Anesthesiologist Oral Pathologist Oral Radiology Provider's Primary Specialty * Provider's Primary Specialty *
Participating Network Types (select all that apply)*	Participating Network Types (select all that apply)* Participating Network Types (select all that apply)* Medicaid AdultMedicaid ChildSpecial Needs ChipMedicare AdvantageCommercial MarketPlace
Office Location Counties (select all that apply)	Select
C2	Select
C3	Select
C4	Select