Provider Directory

Request to Be Added to the Provider Directory

Complete the form below to apply for listing in the Dollar Based Dental provider directory. Applications are reviewed by Eagles and you will be notified of the decision.

1Practice Info

2Contacts

3Agreement

Practice Information

This information will appear in the public provider directory.

Practice / Office Name *

Primary Dentist Name *

NPI Number

Provider Type *

Specialty *

Public Address

Street Address *

Suite / Unit

City *

State *

ZIP *

Public Contact Information

Visible to patients in the provider directory.

Office Phone *

Office Email

Website