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Profession	Apps
Therapy	- - - - - - - - - - - - - - - - - - - - SELECT AN APPLICATION - - - - - - - - - - - - - - - - - - - ANTHEM BLUE CROSS / BLUE SHIELD - Colorado ANTHEM BLUE CROSS / BLUE SHIELD - Nevada ANTHEM BLUE CROSS / BLUE SHIELD - New Hampshire BLUE CROSS / BLUE SHIELD (HMO) - New Mexico BLUE CROSS / BLUE SHIELD - Montana CAL OPTIMA CALIFORNIA CHILDREN'S SERVICES CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) CAPP CARE PPO CAREFIRST BLUE CROSS / BLUE SHIELD (Non-physician Application) CIGNA HEALTHCARE - New Hampshire HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - New Hampshire HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - Rhode Island HEALTH NOW - New York (General/Specialist) HEALTH NOW - New York (General/Specialist) Ontario Region HEALTH NOW - New York (General/Specialist) Syracuse / Utica Region HEALTHSOURCE - South Carolina KEMPER PREFERRED PROVIDER NETWORK NETWORK MEDICAL MANAGEMENT * 03/23/1903 WELLMARK BLUE CROSS / BLUE SHIELD - South Dakota
Vision	- - - - - - - - - - - - - - - - - - - - SELECT AN APPLICATION - - - - - - - - - - - - - - - - - - - AMERICAN ASSOCIATION OF HEALTH PLANS (AAHP) ANTHEM BLUE CROSS / BLUE SHIELD - Colorado ANTHEM BLUE CROSS / BLUE SHIELD - Nevada ANTHEM BLUE CROSS / BLUE SHIELD - New Hampshire AVESIS VISION BLOCK VISION (General/Specialist) BLUE CROSS / BLUE SHIELD (HMO) - New Mexico BLUE CROSS / BLUE SHIELD - Michigan BLUE CROSS / BLUE SHIELD - Montana CAL OPTIMA CALIFORNIA CHILDREN'S SERVICES CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) CAPP CARE PPO CAREFIRST BLUE CROSS / BLUE SHIELD (Non-physician Application) CIGNA HEALTHCARE - New Hampshire CLARITY VISION (General/Specialist) COAST TO COAST VISION COLE MANAGED VISION CARE COLE VISION Credentialing Application (General/Specialist) COLE VISION Re-Credentialing Application (General/Specialist) COORDINATED VISION CARE (MD/DO/OD or Optician) DAVIS VISION - All Other States (General/Specialist) 05/19/1902 DAVIS VISION - District of Columbia (General/Specialist) 02/10/1903 DAVIS VISION - Maryland (General/Specialist) DAVIS VISION - Massachusetts (General/Specialist) 02/18/1903 DAVIS VISION - Michigan (General/Specialist) 01/29/1903 DAVIS VISION - New Jersey (General/Specialist) 02/19/1903 DAVIS VISION - New York (General/Specialist) 02/10/1903 DAVIS VISION - North Carolina (General/Specialist) DAVIS VISION - Pennsylvania (General/Specialist) DAVIS VISION - Texas (General/Specialist) 01/22/1902 DAVIS VISION - Virginia (General/Specialist) 02/02/1903 EXCELLUS BLUE CROSS / BLUE SHIELD - New York (Optometrist Application) EXCELLUS BLUE CROSS / BLUE SHIELD - New York (Uniform Credentialing Application) EXCELLUS BLUE CROSS / BLUE SHIELD - Utica EYE CARE PLAN OF AMERICA (Opthalmologist Credentialing) EYE CARE PLAN OF AMERICA (Optometrist Credentialing) EYE MED (Re-credentialing) EYE MED - (Participation/Location Change Request) 04/03/1902 EYEMED (Credentialing) EYEMED (Employed) HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - New Hampshire HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - Rhode Island HEALTH NOW - New York (General/Specialist) HEALTH NOW - New York (General/Specialist) Ontario Region HEALTH NOW - New York (General/Specialist) Syracuse / Utica Region HIGHMARK - All states except Pennsylvania HIGHMARK BLUE SHIELD - Pennsylvania (General/Specialist) INLAND EMPIRE HEALTH MVP MEDICAL HEALTH PLAN (General/Specialist) OPTICARE HEALTH SYSTEMS PREFERRED CARE - New York (General/Specialist) PRUDENTIAL (Mid-Level Practitioners) SPECTERA VISION SUPERIOR VISION SERVICES (Recredentialing) 10/07/2009 WELLMARK BLUE CROSS / BLUE SHIELD - South Dakota
Medical	- - - - - - - - - - - - - - - - - - - - SELECT AN APPLICATION - - - - - - - - - - - - - - - - - - - AETNA (Recredentialing) Application - CALIFORNIA 01/07/2012 Aetna Provider Credentialing Application 06/11/2012 ALLIED HEALTH PRACTITIONER (for the Helix Rehab Network) AMERICAN ASSOCIATION OF HEALTH PLANS (AAHP) AMERICAN BENEFIT PLAN ADMINISTRATORS - California (General/Specialist) AMERICAN PREFERRED PROVIDER PLAN AMERICAS HEALTH PLAN (for the Cooperating Provider Network) ANTHEM BLUE CROSS (Provider Profile) - CALIFORNIA 05/31/2012 ANTHEM BLUE CROSS / BLUE SHIELD - Colorado ANTHEM BLUE CROSS / BLUE SHIELD - Nevada ANTHEM BLUE CROSS / BLUE SHIELD - New Hampshire ATLANTIS HEALTH PLAN - New York BCBS SC Credentialing Application 12/01/2012 BETTER HEALTH PLANS BLUE CROSS / BLUE SHIELD (HMO) - New Mexico BLUE CROSS / BLUE SHIELD - Illinois BLUE CROSS / BLUE SHIELD - Montana BLUE CROSS / BLUE SHIELD - Texas BLUE CROSS BLUE SHIELD (Non Credentialing) Application - GEORGIA 01/06/2012 BLUE CROSS BLUE SHIELD (Provider Enrollment) Application - NORTH CAROLINA 01/06/2012 BLUE CROSS BLUE SHIELD (Provider Information Change Form) - GEORGIA 01/06/2012 BLUE SHIELD (PIN) Application - CALIFORNIA 05/21/2012 BLUE SHIELD (Recredentialing) Application - CALIFORNIA 03/07/2013 BLUE SHIELD - CA (Credentialing App & Questionnaire) 11/29/2012 Blue Shield Provider Application 12/26/2012 CAL OPTIMA CALIFORNIA CHILDREN'S SERVICES CALIFORNIA MANUFACTURING TECHNOLOGY CONSULTING - (Inspiris) 12/02/2010 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) CAPP CARE PPO CARDINAL HEALTH ALLIANCE (Provider) Application - INDIANA 06/27/2012 CARONDELET - (Initial) 03/28/2011 CARONDELET - (Recred) 06/19/1902 CHN Provider Credentialing , Recredentialing application 06/22/2012 CIGNA (Credentialing) Application 01/07/2012 CIGNA (Recredentialing) Application 04/19/2012 CIGNA HEALTHCARE - New Hampshire CLEVELAND CLINIC FLORIDA HOSPITAL (Staff Membership Application) COMPREHENSIVE HEALTHCARE OPTIONS (Provider Agreement) 10/07/2009 CONSUMER HEALTH NETWORK (Provisional Physician) Corvel Application 07/04/2013 CORVEL CORPORATION (Physician Application) Coventry Provider Information Application 07/05/2013 CPPA-Recredentialing Application 08/21/2012 CYPRESS CARE (Credentialing) Application - CALIFORNIA 04/30/2012 CYPRESS CARE (Location Sheet) - CALIFORNIA 04/30/2012 DESERET MUTUAL 04/16/1902 DIAGNOSTIC VILLAGE (Physician Provider Form 2008) - CALIFORNIA 01/11/2012 Diagnostic Village Addendum B 06/07/2012 Diagnostic Village Recredentialing Application 06/07/2012 FIRST HEALTH 04/16/1902 HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - New Hampshire HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - Rhode Island HEALTH CARE PAYERS COALITION -New Jersey HEALTH NOW - New York (General/Specialist) HEALTH NOW - New York (General/Specialist) Ontario Region HEALTH NOW - New York (General/Specialist) Syracuse / Utica Region HEALTHFIRST HEALTHSOURCE - South Carolina HEALTHSTAR (formerly HealthMark) Heritage Re-credentialing Application 04/24/2014 HERITAGE SUMMIT HEALTHCARE (Recredentialing Review) - FLORDIA 01/05/2012 HERITAGE SUMMIT HEALTHCARE - Florida (Credential Review Application) 01/06/2012 Heritage Summit Healthcare Credentialing - 6/6/2014 06/09/2014 Heritage Summit Re-Credentialing (April 2014) 04/29/2014 Hill Physicians Credentialing Application 2013 02/23/2013 Horizon BCBS (Network Participation) NJ and PA 05/17/2012 HUMANA HEALTHCARE INDIVIDUAL PRACTICE ASSOCIATION OF WESTERN NEW YORK (IPA/WNY) JAI MEDICAL SYSTEMS KEMPER PREFERRED PROVIDER NETWORK KENT & QUEEN ANNE'S HOSPITAL (Appointment to the Medical Staff) LHI Credientialing Application 11/30/2012 MA HCAS Provider Enrollment Form 06/08/2013 MAMSI (Physician) MANAGED CARE CONSULTANTS - Nevada MARIA PARHAM HEALTHCARE SERVICES (Clinical Privileges & Appointment) MARIA PARHAM HOSPITAL (Clinical Privileges & Appointment) Marriott MMCA Network Application 042312 06/27/2012 MARYLAND LAUREL REGIONAL HOSPITAL (Medical Staff Reappointment) MARYLAND PHYSICIANS CARE (MCO) Provider Application MEDCOST (Recredentialing) Application 01/06/2012 MEDFOCUS (Credentialing) Application - CALIFORNIA 05/31/2012 MEDFOCUS (Recredentialing) Application - CALIFORNIA 05/31/2012 MedFocus Physician Application 07/06/2013 MEDICAL REFERRAL SOURCE 07/30/2010 METHODIST HOSPITAL MEDICAL STAFF & CLINICAL PRIVILEGES APP - Kentucky 02/27/1902 MONARCH (Credentialing) Application - CALIFORNIA 02/05/2013 MPA INC (Credentialing) Application - FLORIDA 01/05/2012 MULTIPLAN/PHCS INDIVIDUAL PRACTITIONER APP - Rhode Island 11/08/1902 NEIGHBORHOOD HEALTH PLAN (NHP) NETWORK MEDICAL MANAGEMENT (Physican Assistant) * 04/06/1903 NETWORK MEDICAL MANAGEMENT * 03/21/1903 One Call Provider Application 07/06/2013 ONECALL MEDICAL (Neurodiagnostic Physicians) Application - CALIFORNIA 06/26/2012 ONECALL MEDICAL (Physicians Recredentialing) Application - CALIFORNIA 03/13/2012 OPTACOMP (Clinician) Application - FLORIDA 01/05/2012 OWENSBORO MERCY HEALTH SYSTEM APPPLICATION - Kentucky 11/22/1902 PENNSYLVANIA MEDICAID ENROLLMENT APPLICATION - (General) 01/24/1903 Portamedic Credential Form 06/22/2012 PREMERA (Practitioner) APPLICATION - ALASKA 05/17/2012 PREMERA BLUE CROSS - Washington (Facility) * PREMERA BLUE CROSS / BLUE SHIELD - Alaska (Facility) * Prime Health Initial Cred App 05/26/2013 Procura Management Inc. Network Application 12/12/2015 PRUDENTIAL (Mid-Level Practitioners) PSYCHEALTH* 08/20/1902 QualCare Application for Network Participation 12/12/2015 ROCKPORT HEALTHCARE GROUP (Credentialing) Application - FLORIDA 01/05/2012 SAINT MARYS RECRED APPLICATION - Nevada 10/20/1902 SAME DAY SURGICAL CENTER (Clinical Privileges & Appointment) Scripps Hosp Privilege Application 02/10/2013 Sharp Hosp Privilege Application 02/10/2013 SPN Credentialing Application Master 07/08/2013 Tricare Humana Network App 05/27/2013 TRICARE Provider Application - Alaska 04/15/2013 Tricity Hospital Application 02/10/2013 TriWest Initial Credentialing (California) 05/31/2012 UNIVERSITY HEALTH CARE 04/16/1902 USACARE - Colorado (General) * WELLMARK BLUE CROSS / BLUE SHIELD - South Dakota WEST TEXAS HEALTH PLANS (HMO Blue West Texas)
Dental	- - - - - - - - - - - - - - - - - - - - SELECT AN APPLICATION - - - - - - - - - - - - - - - - - - - Dental Select General (Texas) 05/28/2015 ACCESS - NCA (Associate Agreement) 2009 10/16/2009 ACCESS DENTAL - (Associate Agreement) 12/13/2019 Access Dental - (Associate Agreement) 2012 10/27/2012 ACCESS DENTAL - (General) 10/10/1901 ACCESS DENTAL - (Specialist) 08/22/1902 Access Dental - General Application - (Georgia) 08/31/2012 ACCESS DENTAL - Oregon (General) 2009 11/25/1902 ACCESS DENTAL - Oregon/Washington (Specialty) 2009 11/25/1902 Access Dental - Specialty Application - (Georgia) 06/21/2012 ACCESS DENTAL - Washington (General) 2009 11/25/1902 Access Dental HMO OK AZ 6.2017 06/07/2017 ACCESS HEALTHY FAMILIES - (Facility Application) 04/20/2010 ACCESS PPO PREMIER DHMO - NCA 06/17/2011 ACCESS PROTECTIVE - Arizona (General) 11/03/1902 ACCESS PROTECTIVE - Arizona (Specialty) 11/03/1902 ACCESS PROVIDER CREDENTIAL INFORMATION 07/12/2010 Access. Premier Access CA 3.2024 03/25/2024 ADVANTAGE DENTAL - OR / WA (General) 3.14.2022 03/16/2022 Advantage Dental - Pacific Source 2022 10/22/2022 ADVANTICA 11/12/1902 Advantica-FL 09/18/2012 AETNA PPO & HMO - Arizona (Specialist) Individual Provider Application 07/12/1902 AETNA (California) General/Specialty Application Rev 07-01-09 10/05/2009 Aetna (GP & Specialty) 11.2017 11/14/2017 Aetna (GP & Specialty) 11.2017 WA 11/15/2017 Aetna (GP & Specialty) 2012 10/16/2012 Aetna (GP & Specialty) 2015 10/11/2015 Aetna (GP & Specialty) 2016 08/27/2017 Aetna (GP & Specialty) 9.2013 03/15/2014 AETNA (STDA) - TX 2010 08/23/2010 Aetna (Texas) 06/02/2015 AETNA - (Facility Application) 04/20/2010 AETNA - CA (Add'I Location) 01/17/2011 Aetna - DFW - Recredential App 09/28/2012 Aetna - Indiana 10/10/2012 Aetna - Oklahoma - Recredential App 09/28/2012 AETNA Add Location Form (Attached W9) 06/2009 10/05/2009 Aetna Application TX 102015 11/05/2015 AETNA CREDENTIALING APP - OR/WA/NCA (2009) 10/05/2009 Aetna Dental Application - (Georgia) 02/14/2013 AETNA DENTAL PPO - Arkansas (General) 05/27/2011 AETNA DENTAL PPO - Arkansas (Specialty) 05/13/2011 AETNA DHMO / PPO - CA (General/Specialist) 05/12/2011 AETNA DHMO/PPO - Southern California (General) 10/08/2009 AETNA DHMO/PPO - Southern California (Specialist) 10/08/2009 AETNA DMO & PPO - (Additional Location Form) 10/21/1902 AETNA DMO & PPO - Arizona (General) Associate Provider Application 10/09/2009 AETNA DMO & PPO - California Associate (GP & Specialists 01/01/09) 10/22/1902 AETNA DMO & PPO - Hawaii Associate (GP & Specialists 01/01/09) 10/24/1902 AETNA DMO & PPO - Kansas Associate (GP & Specialists 01/01/09) 10/22/1902 AETNA DMO & PPO - MA (General Dentist) 03/29/2011 AETNA DMO - California Associate (GP & Specialists 01/01/09) 10/23/1902 AETNA DMO - Hawaii Associate (GP & Specialists 01/01/09) 10/23/1902 AETNA DMO / PPO - FL 01/27/2012 Aetna HI 2014 10/23/2014 Aetna Location Add Request-PPO/DHMO 01/16/2013 Aetna OH/IN 2013 02/11/2013 Aetna OK 2014 10/12/2014 AETNA PPO & DHMO - California (General) Individual Dentist Application 10/13/2009 AETNA PPO & DHMO - California (Specialist) Individual Provider Application 10/12/2009 AETNA PPO & DMO - Oklahoma (General / Specialist) 10/10/2012 AETNA PPO & DMO - Oklahoma (Owner) 05/24/2011 AETNA PPO & HMO (General) Dentist Provider Application 10/05/2009 AETNA PPO & HMO - Arizona (General) Individual Dentist App 10/09/2009 AETNA PPO & HMO - California (Specialist) Individual Provider Application 06/06/1902 AETNA PPO & HMO - Colorado (General) Individual Provider Application 10/27/2009 AETNA PPO & HMO - Colorado (Specialist) Individual Provider Application 07/09/1902 AETNA PPO & HMO - Ohio (General/Specialist) 07/11/1902 AETNA PPO & HMO - Oregon (General) Individual Dentist App 10/05/2009 AETNA PPO & HMO - Oregon (Specialist) Individual Provider Application 07/10/1902 AETNA PPO & HMO - Texas (General) Individual Dentist App 10/07/2009 AETNA PPO & HMO - Texas (General/Specialist) Individual Dentist Apllication 08/28/2012 AETNA PPO & HMO - Texas (Owner) Dentist Application 12/03/2009 AETNA PPO & HMO - Texas (Specialist) Individual Dentist Application 11/23/2009 Aetna PPO & HMO - W. Texas (General/Specialist) Individual Dentist Application 09/12/2011 Aetna PPO & HMO - W. Texas (Owner) Dentist Application 09/12/2011 AETNA PPO & HMO - Washington (General) Dentist Provider Application 10/05/2009 AETNA PPO & HMO - Washington (General) Individual Dentist App 10/05/2009 AETNA PPO & HMO - Washington (Specialist) Individual Dentist Application 07/11/1902 AETNA PPO & HMO � Arizona (General) Individual Dentist Application 9/2009 10/22/2009 Aetna PPO & HMO Existing Provider Form 10/05/2009 AETNA PPO - California Associate (GP & Specialists 01/01/09) 10/23/1902 AETNA PPO - Colorado (GP) 01/13/1903 Aetna PPO - STDA 03/28/2019 Aetna PPO/DHMO GP (PA) 04/04/2013 Aetna WA (GP & Specialty) 2015 03/09/2015 Aetna WA 2014 08/26/2014 Aetna- OK (GP & Specialty) 2016 01/21/2016 Aetna- OR (GP & Specialty) 2016 01/22/2016 Aetna- WA (GP & Specialty) 2016 01/22/2016 AFHS - FL (Application) 10/06/2010 Aflac all states 6/2024 06/20/2024 ALTUS DENTAL 06/28/2010 AMERICAN ASSOCIATION OF HEALTH PLANS (AAHP) AMERICAN BENEFIT PLAN ADMINISTRATORS - California (General/Specialist) AMERICAN PREFERRED PROVIDER PLAN AmeriGroup - Dayton 09/20/2012 AmeriGroup - OH 09/20/2012 AMERIPLAN - (Group Office) 04/18/1902 AMERIPLAN - (Lime) 08/16/1902 AMERIPLAN - (Red & Teal) 08/16/1902 AMERIPLAN - New Jersey (Specialist) 02/10/2011 AMERIPLAN - So. Texas (General/Specialist) 02/03/2010 AMERIPLAN - So. TX (General/Specialist) 01/04/2010 AMERIPLAN BENEFIT APPLICATION - 3-16-10 03/16/2010 AMERIPLAN DENTAL AGREEMENT - 3-16-10 03/16/2010 AMERIPLAN DENTAL CHECK LIST - 3-16-10 03/16/2010 Ameriplan Dental Group Provider 7.2019 07/30/2019 AMERIPLAN DENTAL QUESTIONNAIRE - 3-16-10 03/16/2010 AMERIPLAN DENTIST LETTER - 3-16-10 03/16/2010 AMERIPLAN FACT SHEET - 3-16-10 03/16/2010 Ameriplan PPO TX - STDA 03/04/2019 Ameritas Application TX 102015 11/05/2015 AMERITAS - (Facility Application) 04/20/2010 AMERITAS - Oklahoma (Owner) 05/04/2011 Ameritas - STDA 03/01/2019 Ameritas - WA only 12.2019 12/23/2019 AMERITAS CHANGE OF ADDRESS FORM 04/15/1902 AMERITAS DF DISCOUNT PLAN (General/Specialist) Owner Agreement Ameritas Full App (Texas) 05/20/2015 AMERITAS MANAGED DENTAL (Associate Dentist) Prepaid Contract AMERITAS MANAGED DENTAL (Dental Provider) Prepaid Contract AMERITAS PPO - (Owner) 04/16/2012 AMERITAS PPO - (Owner) 2009 11/30/2009 AMERITAS PPO - Arizona (General) 05/08/1902 AMERITAS PPO - California (General) 05/09/1902 AMERITAS PPO - Nevada (General) 05/13/1902 AMERITAS PPO - Rev. 12-09 03/12/2010 Ameritas PPO - STDA 10/2013 12/22/2013 AMERITAS PPO - TN (General) 01/12/2010 Ameritas PPO - VA 08/02/2011 AMERITAS PPO APPLICATION 01/05/2010 AMERITAS PPO PROVIDER REVISION FORM 07/17/1902 Ameritas Provider Update (Texas) 05/20/2015 Anthem - CA - GP & Specialist (Dental Blue - PPO Prudent Buyer 8.2016 08/25/2016 Anthem - GP & Specialist AZ. OR. WA. HI 8.2017 09/25/2017 Anthem - GP (App / Dental Blue - PPO-Prudent) 01.2020 - CA 01/16/2020 ANTHEM - GP (App / Dental Net & Select HMO / PPO-Prudent Buyer /100,200,300 ) 2013 - CA 01/24/2013 ANTHEM - GP (App / Dental Net & Select HMO / PPO-Prudent Buyer) 2014 - CA 11/25/2014 Anthem - GP (App / Dental Net-Select HMO) 03.2016 - CA 04/19/2018 ANTHEM - GP (App/Dental Net-Select/100,200,300/PPO-Prudent Buyer) 2012 10/20/2012 ANTHEM - GP - (App / PPO / Prudent / 100-200-300) 01/17/2011 ANTHEM - GP - (Dental Net / Select HMO) 01/17/2011 ANTHEM - Ortho (App / Dental Net - Dental Select HMO) - 11/2012 - CA 01/24/2013 Anthem - Ortho (App / Dental Net - Select HMO / Golden West HMO) 11.2016 - CA 12/07/2016 ANTHEM - Ortho (App / Dental Net - Select HMO) 2013 - CA 03/12/2014 Anthem - Ortho (App / Dental Net-Select HMO / Golden West HMO) 3.2017 - CA 04/11/2021 Anthem - Ortho (App / Dental Net-Select HMO) 11.2016 - CA 01/07/2017 ANTHEM - Ortho - (App / Dental Net / Select HMO) 10/20/2012 Anthem - Specialist (App / Dental Blue - PPO-Prudent) 01.2020 - CA 01/16/2020 ANTHEM - Specialist (App / Dental Blue Specialty / PPO-Prudent Buyer) 2014 - CA 11/25/2014 ANTHEM - Specialist (App / Dental Blue Specialty / PPO-Prudent) 2013 - CA 01/24/2013 Anthem - Specialist (App / Dental Net - Select HMO / Golden West HMO) 11.2016 - CA 12/04/2016 Anthem - Specialist (App / Dental Net-Select HMO / Golden West HMO) 3.2017 - CA 04/11/2021 ANTHEM - Specialist (App/Specialty Dental Blue/PPO-Prudent Buyer) 2012 10/20/2012 ANTHEM - Specialist - (App / Dental Net / Select HMO) 10/20/2012 ANTHEM - Specialist - (App / Dental Net / Select HMO) 11/2012 - CA 01/24/2013 ANTHEM - Specialist - (App / PPO / Prudent / DB Spec) 01/17/2011 ANTHEM BC DENTAL BLUE PPO - Southern California (General) 03/24/1903 ANTHEM BC DENTAL BLUE PPO - Southern California (General) BRIGHT NOW DENTAL 05/19/1902 ANTHEM BC DENTAL BLUE PPO - Southern California (Specialist) 09/21/1902 ANTHEM BC PRUDENT BUYER - Southern California (General/Specialist) 03/26/1903 Anthem BC/BS PPO (NV GP & Spec) 6.2017 07/05/2017 Anthem BC/BS PPO HI (GP & Spec) 6.2017 07/11/2017 Anthem BC/BS PPO NV (GP & Spec) 8.2017 08/27/2017 ANTHEM BCBS - Nevada (General) 04/02/2010 ANTHEM BLUE CROSS - CA (General) 04/15/2011 ANTHEM BLUE CROSS - CA (Specialist) Dental Net & Select HMO 04/25/2011 ANTHEM BLUE CROSS - Southern Cal Rev. 2009 12/14/2009 ANTHEM BLUE CROSS / BLUE SHIELD - Application & Contracts - CO (General) 11/17/2009 ANTHEM BLUE CROSS / BLUE SHIELD - Application & Contracts - CO (Specialist) 11/18/2009 ANTHEM BLUE CROSS / BLUE SHIELD - California (PPO 100 200 300) 05/22/1902 ANTHEM BLUE CROSS / BLUE SHIELD - Nevada (Specialist) 04/03/1902 ANTHEM BLUE CROSS / BLUE SHIELD - New Change Request Form 10/03/1902 ANTHEM BLUE CROSS / BLUE SHIELD - New Hampshire ANTHEM BLUE CROSS / BLUE SHIELD - Ohio (General) 05/02/1902 Anthem Blue Cross NV (GP & SP) 2016 03/25/2016 Anthem Blue Cross PPO NV (GP & SP) 2017 02/04/2017 ANTHEM BLUE CROSS PRUDENT BUYER PPO - CA (General / Specialist) 05/06/2011 ANTHEM DENTAL BLUE & PPO - So Cal (Specialty) 2010 02/16/2010 ANTHEM DENTAL BLUE & PPO - So Cal 2010 02/16/2010 ANTHEM DENTAL NET - CA (Ortho) 05/18/2011 ANTHEM DENTAL NET - CA (Specialist) 05/18/2011 ANTHEM SELECT HMO - CA (Ortho) 05/24/2011 ANTHEM SELECT HMO - CA (Specialist) 05/18/2011 ANTHEM SENIOR SECURE - CA (General / Specialist) 05/18/2011 Anthem, Wellpoint-GP, Specialists NV 5/2024 05/16/2024 Anthem-Unicare-Wellpoint AZ, OR, HI, OK, KS 6.2023 06/08/2023 Application - TriWest Initial Credentialing 2010-03-22 05/31/2012 Application Packet Star Health 07/23/2011 Application Packet-tx chip 07/22/2011 ARGUS - FL 02/16/2012 Argus Dental - Specialty Application - (Georgia) 11/15/2012 Argus Dental Application - (Georgia) 11/15/2012 ARGUS DENTAL PPO - Florida 02/07/1902 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS) - Arizona 12/03/1902 Arkansas Medicaid 09/28/2011 ARRIN CONSULTING (Joint Benefit Trust Program) ASSURANT - (General/Specialist) 03/21/1902 ASSURANT - Colorado (General/Specialist) 09/21/1902 ASSURANT - Florida (Specialy contracts w/ agreements only/no app) 05/10/1902 Assurant - General Application - (Georgia) 08/31/2012 Assurant - Specialty Application - (Georgia) 01/31/2012 ASSURANT DENTIST AGREEMENT - (Office Profile) 3-16-10 03/18/2010 Assurant DHA - NJ 08/09/2011 Assurant DHA - VA 08/04/2011 ASSURANT DHMO - FL 02/16/2012 ASSURANT DMO - Oklahoma (General / Specialist) 05/04/2011 ASSURANT DMO - Oklahoma (Owner) 05/04/2011 ASSURANT EMPLOYEE BENEFITS 04/10/1902 Assurant Employee Benefits (PA-NJ/GP-SP) 01/19/2013 ASSURANT EMPLOYEE BENEFITS - Texas (General) 08/31/1902 ASSURANT EMPLOYEE BENEFITS - Texas (Owner) 12/04/2009 ASSURANT EMPLOYEE BENEFITS - Texas (Specialty) 09/01/1902 ASSURANT EMPLOYEE BENEFITS UDC - Arizona 10/09/2009 Assurant PPO - TN 05/29/2012 Assurant PPO - TN Specialist 05/29/2012 Assurant PPO 08/2015 09/04/2015 Assurant PPO 2016 03/26/2016 ASSURANT UDC - (Facility Application) 04/20/2010 Assurant. DHA - WA. 8..2018 08/16/2018 Avesis Application-GA Medicaid - (Georgia) 11/18/2012 AVIA DENTAL - NJ (Specialist) 03/22/2011 BCBS 11/19/2010 BCBS - PCF (TN) 12/05/2011 BCBS - TN (add location) 11/21/2011 BCBS of Arkansas - Add Location Form 09/19/2012 BCBS of AZ (GP & Specialty) 2012 10/11/2012 BCBS of AZ (GP & Specialty) 2014 03/19/2014 BCBS of AZ 6.2020 07/25/2020 BCBS of AZ 6.2020 CAQH 07/25/2020 BCBS OF ID - Spkoane, WA Only (General/Specialist) 2010 09/24/2010 BCBS PPO - Texas (Owner) 01/15/2010 BCBS PRUDENT BUYER - 2010 09/17/2010 BCBS-Wellpoint Application - (Georgia) 01/31/2012 BETA HEALTH ASSOCIATION 10/07/2009 BETA HEATLH ASSOCIATION - Colorado (Specialist Dental Agreement) * BLUE CROSS / BLUE SHIELD (HMO) - New Mexico BLUE CROSS / BLUE SHIELD - Arizona (HMO) 02/15/1902 BLUE CROSS / BLUE SHIELD - Arizona 2010 02/16/2010 BLUE CROSS / BLUE SHIELD - California (General) 10/07/2009 BLUE CROSS / BLUE SHIELD - California (General/Specialist) Senior Secure Application 05/12/2011 BLUE CROSS / BLUE SHIELD - Georgia 01/13/1902 BLUE CROSS / BLUE SHIELD - Louisiana 02/24/1902 BLUE CROSS / BLUE SHIELD - Massachusetts 05/17/1902 BLUE CROSS / BLUE SHIELD - Montana BLUE CROSS / BLUE SHIELD - Tennessee (Pre-Application) * BLUE CROSS BLUE SHIELD - Arizona (Additional Location) 10/22/2009 BLUE CROSS BLUE SHIELD - Arizona (Contracting Request & Information Form) 10/22/2009 BLUE CROSS BLUE SHIELD - Arizona - Cred. App Only (BCBS AZ & Tricare) 09/20/1902 BLUE CROSS BLUE SHIELD - IL (Service Agreement) 3-12-10 03/12/2010 BLUE CROSS BLUE SHIELD - IL (Signature Page) 3-12-10 03/12/2010 BLUE CROSS DENTAL NETWORK / DENTAL SELECT HMO - (Specialist) 2009 10/26/2009 BLUE CROSS DENTAL NETWORK / DENTAL SELECT HMO - Southern California (Specialist) 09/05/1902 BLUE CROSS DENTAL NETWORK / DENTAL SELECT HMO � Southern California (Orthodontist) 06/04/1902 BLUE CROSS DENTAL NETWORK HMO - (Specialist) 10/12/2009 BLUE CROSS DENTAL NETWORK/DENTAL SELECT HMO - CALIFORNIA (ORTHODONTIST) 10/05/2009 BLUE CROSS DENTAL NETWORK/DENTAL SELECT NETWORK HMO - CALIFORNIA (SPECIALIST) 10/05/2009 BLUE CROSS OF CALIFORNIA - DentalNet (General) 01/19/1903 BLUE CROSS OF CALIFORNIA - SCA DentalNet (General) 07/15/1902 BLUE CROSS OF CALIFORNIA DENTAL NETWORK - Dental Select HMO (Ortho) 10/12/2009 BLUE CROSS PRUDENT BUYER PPO - California (General/Specialist) 10/15/2009 BLUE CROSS WELLPOINT/UNICARE PPO - Arizona 10/22/2009 BLUE CROSS/BLUE SHIELD - Minnesota 08/03/1902 BLUE CROSS/BLUE SHIELD -Florida 02/16/2012 BLUE CROSS/BLUE SHIELD PPO & HMO - Arizona (General/Specialist) 10/09/2009 BSBC AZ 2010 GP & Specialty 09/19/2011 CA Dental Network - General/Specialty/Ortho (Interdent Use Only) - 10/2016 08/28/2017 CAL OPTIMA CALIFORNIA BENEFITS DENTAL PLAN 10/08/2011 CALIFORNIA BENEFITS DENTAL PLAN - Specialist 10/08/2011 CALIFORNIA CHILDREN'S SERVICES CALIFORNIA DENTAL NETWORK (General) Advantage Plan 10/07/2009 CALIFORNIA DENTAL NETWORK - (General) NCA App 10/16/2009 CALIFORNIA DENTAL NETWORK - (General/Specialist) 10/05/2009 CALIFORNIA DENTAL NETWORK - (Ortho) 04/11/1902 CALIFORNIA DENTAL NETWORK - (Specialist) 04/11/1902 CALIFORNIA DENTAL NETWORK - (Verification Form) 03/28/2011 CALIFORNIA DENTAL NETWORK - Associate (Interdent Use Only eff 01-01-11) 02/01/2011 CALIFORNIA DENTAL NETWORK - CA (General) 04/14/2011 California Dental Network - General/Owner (Interdent Use Only) 04/11/2014 California Dental Network - Ortho (Interdent Use Only) 04/11/2014 CALIFORNIA DENTAL NETWORK - Ortho (Ortho Agreement Cal Benefits) 04/14/2011 California Dental Network - Specialist (Interdent Use Only) 04/10/2014 CALIFORNIA DENTAL NETWORK - Specialty (Spec Agreement Cal Benefits) 04/14/2011 California Participating Practitioner Application-Revision 2013 04/19/2015 CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) Capitol Dental Care (CDC) 05.2019 07/31/2019 CAPITOL DENTAL CARE - Oregon 03/14/1903 Capitol Dental Care 09.2015 09/09/2015 Capitol Dental Care Form 2016 12/22/2015 Capitol Dental Care Full App 2016 01/26/2016 Capitol Dental Care Recred 09.2015 09/09/2015 Capitol Dental Care Recredentialing 2016 01/26/2016 CAPP CARE PPO CAQH - Maryland 07/05/2012 CAQH - Ohio 05/17/2012 CAQH AZ 1.2018 01/24/2018 CAQH Standard Application (2014) 03/05/2014 Care First AZ Revised 07/2009 10/05/2009 CareFirst / Anthem - MD/VA 08/12/2011 Carefirst BCBS Auth Form (VA-MD) 08/09/2011 CAREFIRST BLUE CROSS / BLUE SHIELD (Non-physician Application) CAREIGNTON - Oklahoma 08/10/2011 CAREIGNTON - Texas (General/Specialist) 11/30/2009 CAREIGNTON DENTAL PPO APPLICATION - July 2010 02/16/2012 Careignton Existing Provider location Form 10/05/2009 Careington (GP & SP) 6.23.2022 07/22/2022 Careington (WA) 6.2017 07/05/2017 CAREINGTON - (General/Specialist) Provider Add Location Form - 2007 04/16/1903 CAREINGTON - (General/Specialist) Provider Add Location Form - Revised 2008 08/07/1902 CAREINGTON - Arkansas 05/13/2011 CAREINGTON - CA (All) 04/25/2011 CAREINGTON - CA (Group Agreement) / All 04/25/2011 CAREINGTON - OR/WA (Application Revised) 2009 10/28/2009 CAREINGTON - Oregon 09/08/2010 CAREINGTON - So. TX (Revised) 7 / 2010 09/08/2010 Careington - Texas (General/Specialist) 05/16/2013 Careington - Texas - Add Location Form 09/19/2012 CAREINGTON - TN & Houston (General/Specialist) 2010 10/19/2010 CAREINGTON ADD LOCATION FORM - 8/2010 09/10/2010 Careington App - TN (General/Specialist) Revised 2011 06/11/2012 Careington Application - (Georgia) 06/21/2012 Careington Dental Application (Georgia) 08/31/2012 CAREINGTON DENTAL NETWORK PROVIDER - VA / MD (Application Agreement) 07/ 09 06/24/2010 Careington Dental PPO Application - Sept 2010 09/16/2011 CAREINGTON DENTAL PPO APPLICATION - September 2012 10/03/2012 Careington Full App (Texas) 06/03/2015 Careington Maryland 2011 07/23/2011 Careington OK (GP & SP) 2.2017 03/04/2017 CAREINGTON PPO (General/Specialist) Individual Provider - Revised 2007 01/23/1902 CAREINGTON PPO (General/Specialist) Individual Provider - Revised 2008 09/30/1902 CAREINGTON PPO - Southern California (General/Specialist) - Revised 2008 10/06/1902 CAREINGTON PPO - STDA 03/28/2019 Careington recred - STDA 06/17/2018 CAREINGTON-FL 08/30/2012 CASCADE DENTAL - Agreement Only * CB - HD RECREDENTIALING - So. TX 05/19/2010 CBO - All Markets Dentegra 9/2012 02/19/2013 CBO - All States (Access/Premier - GP/SP - New/Additional Location) 08/12/2011 CBO - All States (Careington GP/SP) 09/17/2012 CBO - All States (Total Dental New DR. and recred GP/SP) 08/18/2011 CBO - All States Maverest 03/08/2013 CBO - Arizona - New GP (Non Signature Pages) 1 to 2 03/20/2013 CBO - Arizona - New GP (Non Signature Pages) 2 to 2 10/14/2012 CBO - Arizona - New GP (Signature Pages) 1 to 6 03/20/2013 CBO - Arizona - New GP (Signature Pages) 2 to 6 10/14/2012 CBO - Arizona - New GP (Signature Pages) 3 to 6 10/14/2012 CBO - Arizona - New GP (Signature Pages) 4 to 6 10/14/2012 CBO - Arizona - New GP (Signature Pages) 5 to 6 10/14/2012 CBO - Arizona - New GP (Signature Pages) 6 to 6 10/14/2012 CBO - AZ (B/C - BS GP/SP new DR.) 08/16/2011 CBO - AZ (Cigna HMO & PPO GP new Dr.) 03/22/2011 CBO - AZ (DBP GP/SP) new DR. 08/16/2011 CBO - AZ - Add location packet 2013 03/18/2013 CBO - CA, OR, WA (Cigna - GP - New Dr.) 07/26/2011 CBO - 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NCA - GP De Novo (Non Signature Pages) 1 of 2 10/25/2012 CBO - NCA - GP De Novo (Non Signature Pages) 2 of 2 03/30/2013 CBO - NCA - GP De Novo (Signature Pages) 1 of 2 10/25/2012 CBO - NCA - GP De Novo (Signature Pages) 2 of 2 03/30/2013 CBO - NCA, OR & WA (DBP - GP - Provider App) 09.06.11 09/22/2011 CBO - NCA, OR & WA (DBP - OR - Provider App) 09.06.11 09/22/2011 CBO - NCA, OR & WA (DBP - SP - Provider App) 09.06.11 09/22/2011 CBO - OR - Add location packet 2013 04/12/2013 CBO - OR, WA, UT (Cigna HMO GP) 10/27/2010 CBO - OR, WA, UT (Cigna HMO SP) 10/27/2010 CBO - Oregon - GP (New Dr.) Non Signature pages Part 1 of 2 04/03/2013 CBO - Oregon - GP (New Dr.) Non Signature pages Part 2 of 2 03/17/2013 CBO - Oregon - GP (New Dr.) Signature pages Part 1 of 3 03/20/2013 CBO - Oregon - GP (New Dr.) Signature pages Part 2 of 3 04/03/2013 CBO - Oregon - GP (New Dr.) Signature pages Part 3 of 3 10/07/2012 CBO - Oregon Denovo (GP) - Non Signature pages 10/23/2012 CBO - Oregon Denovo (GP) - Signature pages 10/23/2012 CBO - 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Oklahoma (General/Specialist) CIGNA DENTAL COMBINED DHMO & PPO 08/13/1902 CIGNA DENTAL COMBINED DHMO & PPO (Interdent) 02/01/2011 CIGNA DENTAL COMBINED DHMO & PPO - Texas 10/20/2011 CIGNA DENTAL COMBINED DHMO & PPO - TEXAS (SPECIALIST) 03/13/2012 Cigna Dental Combined DHMO/PPO - CA (General) 09.2018 09/24/2018 Cigna Dental Combined DHMO/PPO - CA (Specialty) 09.2018 09/24/2018 CIGNA DENTAL DHMO & PPO - Oklahoma 05/13/2011 CIGNA DENTAL DHMO - Texas (Owner) 11/24/2009 CIGNA DENTAL DHMO - Texas (Specialist) 11/24/2009 CIGNA DENTAL DHMO/PPO - Northern California (2008) 10/05/2009 CIGNA DENTAL HMO - Arizona (General) 10/08/2009 CIGNA DENTAL HMO - Arizona (Specialist) 10/08/2009 CIGNA DENTAL HMO - California (General) 10/07/2009 CIGNA DENTAL HMO - California (Specialist) 10/05/2009 CIGNA DENTAL HMO - Nevada (Owner) 04/10/1902 CIGNA DENTAL HMO - Southern California (General) 10/08/2009 CIGNA DENTAL HMO - Utah (General) 02/02/1903 Cigna Dental HMO Specialist application 10/05/2009 Cigna Dental HMO specialist application/contract - Texas revised 2008 10/05/2009 CIGNA DENTAL PPO (General/Specialist) 2008 10/05/2009 CIGNA DENTAL PPO - Arkansas 05/13/2011 CIGNA DENTAL PPO - Texas (General/Specialist) 08/16/2011 Cigna Dentist Change Form TX 102015 12/18/2015 CIGNA DHMO - (General) Rev. 08 09/03/1901 CIGNA DHMO - (Specialist) 12/1/2009 08/19/2010 CIGNA DHMO - (Specialist) 2009 10/29/2009 CIGNA DHMO - (Specialist) Rev. 08 09/03/1901 CIGNA DHMO - Colorado (Specialist) 02/02/2011 CIGNA DHMO - Oklahoma - Application/Contract Rev. 08 06/01/1902 CIGNA DHMO - Texas (General) 11/24/2009 CIGNA DHMO - TN (Specialist) 03/16/2010 CIGNA DHMO / PPO - CA (Page 4-29) 04/04/2011 CIGNA DHMO CONTRACT - California (Rev. 08) 03/22/1902 CIGNA DHMO PPO 01/02/1902 CIGNA DHMO PPO - Add Location Form (Existing Providers Only) 03/02/2013 CIGNA DHMO SPECIALIST CONTRACT - California (Rev. 08) 03/23/1902 CIGNA DHMO STANDARD CONTRACT - California (Rev. 08) 03/23/1902 CIGNA FACILITY APP / ADD LOCATION 06/25/2010 Cigna GP - AZ 9.18.18 09/24/2018 CIGNA HEALTHCARE - New Hampshire CIGNA HMO/PPO (General Associate) Interdent 10/05/2009 Cigna OK 12.2014 12/16/2014 Cigna PPO & DHMO (Texas) 05/25/2015 Cigna PPO & DHMO 4.2017 04/17/2017 Cigna PPO & DHMO AZ 12.2016 12/29/2016 Cigna PPO & DHMO Specialty AZ 4.2017 04/17/2017 Cigna PPO (Specialist) - TN 11/21/2011 CIGNA PPO - CA (Only start on page 3-12) 04/04/2011 Cigna PPO - California (General/Specialist) 08/2009 10/05/2009 Cigna PPO - STDA 05/31/2017 Cigna PPO - STDA 05/31/2017 05/27/2018 CIGNA PPO - TN (Specialist) 10/11/2010 Cigna PPO -HI, KS (General/Specialist) 08/2009 10/05/2009 CIGNA PPO / DHMO - TN (General) 03/16/2010 CIGNA PPO / DHMO - WA & OR (General) 2009 10/15/2009 Cigna PPO app/agrmt (specialist) MI state 05/05/2017 CIGNA PPO APPLICATION - Revised 11-20-2009 11/23/2009 Cigna PPO/DHMO - California (General) 08/2009 10/05/2009 Cigna PPO/DHMO - TN (General) 12/09/2011 CIGNA PPO/DHMO -WA & OR (Specialist) 2009 10/05/2009 Cigna PPO/DMO (General) - MD 08/08/2011 Cigna PPO/DMO (General) - PA 08/10/2011 Cigna PPO/DMO (General) NJ 08/10/2011 Cigna PPO/DMO (General) VA 08/02/2011 Cigna PPO/DMO (Specialist) - MD 08/08/2011 Cigna PPO/DMO (Specialist) - PA 08/10/2011 Cigna PPO/DMO (Specialist) NJ 08/10/2011 Cigna PPO/DMO (Specialist) VA 08/02/2011 Cigna SP - AZ 9.18.18 09/24/2018 CNA APPLICATION 01/19/2011 Coastal Dental & Gold - Application (California General) Revised 07.09 10/05/2009 COASTAL DENTAL - (Oral Surgery) 02/11/1902 COASTAL DENTAL - (Periodontist) 02/11/1902 COASTAL DENTAL - So Cal (Endo) 09 10/05/2009 COASTAL DENTAL - So Cal (General) 09 10/05/2009 COASTAL DENTAL - So Cal (Ortho) 09 10/05/2009 COASTAL DENTAL - So Cal (OS) 09 10/05/2009 COASTAL DENTAL - So Cal (Perio) 09 10/05/2009 COASTAL DENTAL � (Orthodontist) 02/08/1902 COASTAL DENTAL GOLD PLAN - Eff. 2008 11/06/1902 Coastal Dental GP 2015 11/07/2015 Coastal GP/SP (11/15) 11/11/2015 COMMUNITY DENTAL SERVICES - CA (General) 05/31/2011 COMMUNITY DENTAL SERVICES - CA (Oral Surgeon) 05/31/2011 COMMUNITY DENTAL SVCS (Smilecare) - CA (Endo) 05/24/2011 COMMUNITY DENTAL SVCS (Smilecare) - CA (Endo) 05/24/2011 COMMUNITY DENTAL SVCS (Smilecare) - CA (Ortho) 05/24/2011 Comp Benefits DMO - Indiana 56th & Avon only 09/20/2012 Comp Benefits PPO - OH & Indiana 09/20/2012 COMPDENEFITS DENTAL (General/Specialist) W/O Agreement 02/16/2012 COMPREHENSIVE HEALTHCARE OPTS - Colorado (General) 10/27/2009 Connection - GEHA Add Location Form 102015 11/06/2015 CONNECTION DENTAL - OR & WA (Interdent Only) 05/26/2010 Connection Dental (GEHA) - TN 05/17/2012 CONNECTION DENTAL (General/Specialist) 10/05/2009 CONNECTION DENTAL - (App/Agreement) Jan 2010 05/07/2010 CONNECTION DENTAL - (New Provider Form) 10/31/1902 CONNECTION DENTAL - Application Only 09/16/2013 CONNECTION DENTAL - Arkansas 05/13/2011 CONNECTION DENTAL - CA (All) 04/21/2011 CONNECTION DENTAL - CA.HI (Interdent) 10/05/2009 CONNECTION DENTAL - New Jersey (General/Specialist) 02/08/1903 CONNECTION DENTAL - Oklahoma 05/04/2011 CONNECTION DENTAL - So Cal (Rev. 2009) 12/18/2009 Connection Dental _ Application Only 2011 07/22/2011 Connection Dental All State 5.2025 05/27/2025 CONNECTION DENTAL APP 07/23/2011 Connection Dental app/agrmt (specialist) KS state 01/13/2017 CONNECTION DENTAL APPLICATION - California & Hawaii Only 11/06/1902 Connection Dental/GEHA KS (SP) app/agrmt 12.2016 01/12/2017 Corvel Preferred Provider Application - Illinois 12/29/2016 DBP (GP & SP) AZ 2020 05/26/2020 DBP - (GP & SP) OK 2020 05/26/2020 DBP - CA (General / Specialist) 05/02/2011 DBP - HI (GP & SP) 4.17 04/14/2017 DBP - UHC Full App (Texas) 05/25/2015 DBP / NPD - So. TX (General/Specialist) 03/02/2011 DBP / NPD ADD LOC - So. TX (General/Specialist) 11/04/2010 DBP AZ InterDent GP & SP 2011 12/30/2011 DBP PPO 2014 10/24/2014 DBP recred - STDA 06/19/2017 DBP Specialist - TN 11/14/2011 DBP-TX/APP/ADD/RECRED-2012 03/13/2012 DBP/NPD - Texas (General/Specialist) 08/20/2011 DBP/UHC GP & SP AZ 1.2018 01/24/2018 DDIC - PA 08/09/2011 DDIC - TX 06/2012 06/06/2012 DDIC - VA 08/02/2011 DDIC - VA 08/12/2011 DDIC-6/2012 02/20/2013 DE CARE DENTAL NETWORK - Southern California (GP & SP) Individual Dentist Agreement 10/08/2009 DeCare (GP & Spec) KS only 10.2017 10/09/2017 Decare 03.2016 08/27/2017 DeCare 6.2023 06/08/2023 DeCare app/agrmt (GP & SP) all states except CA, 2014 01/02/2017 DeCare app/agrmt (specialist) MI state 03/27/2017 DECARE DENTAL - CO (Credentialing Application) 10/19/2010 Decare Dental Application - (Georgia) 08/31/2012 DECARE DENTAL NETWORK (Contracting Agreement) 10/07/2009 DECARE DENTAL NETWORK - Oklahoma (GP/Specialist) 06/2009 10/05/2009 Decare Dental Network 2012 08/31/2012 DECARE DENTAL NETWORK Application all except California individual agreement 10/05/2009 DeCare HI 10.2014 10/26/2014 DeCare NV 2014 11/07/2014 DeCare OK 11.2014 11/08/2014 DECARE PPO - New Jersey (Specialist) 02/10/2011 Delta (GP & Spec) AZ 09.2017 01/08/2018 Delta (GP & Spec) NV 09.2017 10/12/2017 DELTA - DELTACARE APP - FL 12/17/2012 DELTA CARE - Arizona (General) 05/28/1902 DELTA CARE - Arizona (General) 01/23/1902 DELTA CARE - Arizona (Orthodontist) 01/18/1902 DELTA CARE - California (Orthodontist) 04/13/1903 DELTA CARE - California (Orthodontist) Owner Agreement 07/25/1902 DELTA CARE - California (Specialist) 04/13/1903 DELTA CARE - California (Specialist) Owner Agreement 12/07/1901 DELTA CARE - CO (Ortho) 04/15/2010 DELTA CARE - Colorado (General/Specialist) 06/13/1902 DELTA CARE - Florida (Ortho w/ Agreement) 03/02/1903 DELTA CARE - Ohio 05/02/1902 DELTA CARE - So. TX 08/31/2010 DELTA CARE - Southern California - (General) 10/19/1901 Delta Care - Texas 05/16/2013 DELTA CARE - Texas (Orthodontic) App w/ Agreement 02/19/2010 Delta Care - Texas - Recredentialing 05/19/2013 DELTA CARE - Virginia (Provider Agreement) * DELTA CARE FACILITY APPLICATION 05/21/2010 DELTA CARE HMO - Nevada (Owner) Delta Care OR GP 10/16/2024 Delta Care OR Specialist - Ortho 10.2024 10/16/2024 Delta Care OR Specialist 10.2024 10/16/2024 DELTA CARE USA PMI - NCA 2010 11/23/2010 DELTA CARE USA - Arizona (Orthodontist) 10/22/2009 DELTA CARE USA - Nevada (Associate) 12/31/1901 Delta Care USA - Spc Agreement - OH & Indiana 09/20/2012 DELTA CARE USA PMI - CA (Specialty) 04/01/2011 DELTA CHIP PROGRAM - Texas (Application) 08/05/2011 Delta Dental PPO 102015 01 5-13 11/07/2015 Delta Dental (Notice of Address change/Additional Location) - Georgia 08/08/2012 DELTA DENTAL - (Notice of Address Change / Additional Location) 11/02/2009 DELTA DENTAL - (Premier/PPO) NCA 2009 10/05/2009 DELTA DENTAL - California (Credentialing Survey) 01/05/2010 DELTA DENTAL - California (Office Information for Online Dentist Directory) 11/05/2009 DELTA DENTAL - GA (Credentialing Forms Only) Revised 06/2010 09/27/2010 DELTA DENTAL - Georgia (Agreement w/ Fee Filing Listing) 03/02/1903 DELTA DENTAL - IL (Premier App) 3-19-10 03/23/2010 Delta Dental - Indiana 10/11/2012 DELTA DENTAL - Oklahoma (Premier & PPO ) 07/23/2010 Delta Dental - Oklahoma - PPO-Premier-Patient Direct (General) 09/28/2012 Delta Dental - Oklahoma - PPO-Premier-Patient Direct (Specialty) 09/28/2012 DELTA DENTAL - Stardent (Owner) 08/05/2011 Delta Dental - Stardent (Provider) 12/15/2011 DELTA DENTAL - Texas (Chip) 01/05/2012 DELTA DENTAL - Texas (DPO & Premier) 02/09/2010 Delta Dental Agreements - Dayton OH 09/20/2012 Delta Dental Application - (Georgia) 04/26/2013 Delta Dental CA (General/Specialist Premier & PPO 2022 08/10/2022 Delta Dental CA PPO. Premier. Legion. Medicare 2.2025 02/28/2025 DELTA DENTAL DIRECT NETWORK (General) - Oklahoma 06/23/2012 Delta Dental DPO & Prem - STDA 04/04/2019 DELTA DENTAL DPO - California 07/14/1902 Delta Dental DPO Amendment 102015 11/06/2015 Delta Dental EFT Form 102015 11/07/2015 DELTA DENTAL HEALTHY FAMILIES - (Facility Application) 05/21/2010 DELTA DENTAL HEALTHY FAMILIES - CA (Associate) 03/01/2010 DELTA DENTAL HEALTHY FAMILIES - CA (Owner) 03/01/2010 DELTA DENTAL LEGION (Tricare Retiree) - CA (General / Specialist) 01/2011 12/14/2010 Delta Dental Legion - All States, 03/2024 03/07/2024 Delta Dental Medicaid - Texas (Owner) 02/08/2012 Delta Dental Medicaid, TX Chip & Starhealth (Owner) 2012 06/25/2012 Delta Dental of Arkansas - Add Location Form 09/19/2012 Delta Dental of Arkansas - Recredentialing Application 09/19/2012 Delta Dental of OK GP Premier, PPO, PDN - 8.2023 08/09/2023 Delta Dental of OK SP Premier, PPO, PDN - 8.2023 08/09/2023 Delta Dental of OR (MODA-ODS) 7.2023 07/13/2023 Delta Dental of OR - Recred 12/22/2021 Delta Dental of Washington (WDS) 2021 09/23/2021 Delta Dental of Washington 2016 03/02/2016 Delta Dental of Washington Addtl Loc 2016 03/02/2016 Delta Dental Patient Direct Network - Oklahoma 12/19/2012 DELTA DENTAL PLAN - WASHINGTON DENTAL SERVICE 10/05/2009 DELTA DENTAL PLAN - Arizona (Premier & Preferred) 10/05/2009 DELTA DENTAL PLAN - Arizona (Premier & Preferred) Revised 2010 12/06/2010 DELTA DENTAL PLAN - California (Change of Address) 10/05/2009 DELTA DENTAL PLAN - California (General) InterDent Only DELTA DENTAL PLAN - California (General/Specialist) Premier Agreement DELTA DENTAL PLAN - California (Sale of Practice) 10/05/2009 DELTA DENTAL PLAN - California (State Government Programs) 10/07/2009 DELTA DENTAL PLAN - California (TIN Request) 10/05/2009 DELTA DENTAL PLAN - Colorado (Preferred Option Agreement) 10/05/2009 DELTA DENTAL PLAN - Colorado(Premier Agreement) 10/05/2009 DELTA DENTAL PLAN - Credentialing Survey 07/14/1902 DELTA DENTAL PLAN - Florida (Credentialing Survey W/O fee agreement) 03/30/2012 DELTA DENTAL PLAN - Illinois (Premier & PPO) 10/05/2009 DELTA DENTAL PLAN - Massachusetts (Group) 05/25/1902 DELTA DENTAL PLAN - Massachusetts (Individual) 05/19/1902 DELTA DENTAL PLAN - Massachusetts (Managed Care Application) 03/19/1903 DELTA DENTAL PLAN - Massachusetts (Premier) 03/19/1903 DELTA DENTAL PLAN - Minnesota 10/21/1902 DELTA DENTAL PLAN - New Jersey (Premier Specialist) 2/2009 10/05/2009 DELTA DENTAL PLAN - New Mexico (General/Specialist) DPO & Premier 01/05/2012 DELTA DENTAL PLAN - Southern California (Associate) Healthy Families Program 10/08/2009 DELTA DENTAL PLAN - Southern California PPO 07/07/1902 DELTA DENTAL PLAN - Tennessee (General) PPO 03/03/1902 DELTA DENTAL PLAN - Tennessee (General/Specialist) 10/07/2009 DELTA DENTAL PLAN - Tennessee (Specialist) PPO 10/07/2009 DELTA DENTAL PLAN - Texas 01/11/2010 DELTA DENTAL PLAN - Texas DHMO (General) * DELTA DENTAL PLAN - Texas DHMO (Orthodontist) * DELTA DENTAL PLAN - Texas DHMO (Specialist) * Delta Dental Plan - Utah (general & Specialist) Premier and PPO 10/05/2009 DELTA DENTAL PLAN - Virginia DELTA DENTAL PLAN - Virginia (Fee Listings) DELTA DENTAL PLAN - Wisconsin 10/27/2010 Delta Dental Plan AZ 2010 GP & Spec (Premier & Preferred) 09/19/2011 DELTA DENTAL PLAN DPO & PREMIER - Texas (General/Specialist) 09/07/2011 DELTA DENTAL PLAN DPO & PREMIER -Nevada (General) 01/04/2012 Delta Dental Plan DPO & Premier-Nevada (General) 2013 05/01/2013 DELTA DENTAL PLAN PPO - California 11/02/2009 Delta Dental Plan Premier, PPO, & Healthy Families - California (General/Specialist) 2013 10/07/2013 Delta Dental Plan Premier, PPO, Healthy Families - California 09/28/2011 DELTA DENTAL PPO & PREMIER - (Commerical Boeing Application) 2009 10/05/2009 DELTA DENTAL PPO & PREMIER - Arizona (General/Specialist) 2009 10/05/2009 DELTA DENTAL PPO & PREMIER - Oklahoma (General / Specialist) 05/04/2011 DELTA DENTAL PPO - Arizona 10/22/2009 DELTA DENTAL PPO - CO (Standard Agreement only) rev 8/2008 10/19/2010 DELTA DENTAL PPO - Maine (Premier) 10/05/2009 Delta Dental PPO Network - Oklahoma 12/19/2012 DELTA DENTAL PPO PREMIER COMMERCIAL - (Facility Application) 04/20/2010 DELTA DENTAL PREMIER & PPO - Arkansas 05/13/2011 DELTA DENTAL PREMIER - CA (Credentialing Form) 10/05/2009 Delta Dental Premier Agreement 102015 11/07/2015 Delta Dental Premier Network - Oklahoma 12/19/2012 DELTA DENTAL PROJECT HERO -Washington (General/Specialist) 2009 10/05/2009 Delta Dental recred - STDA 04/03/2018 Delta Dental TIN Request Form 102015 11/07/2015 DELTA HEALTH FAMILIES - NCA 2009 01/05/2010 DELTA HEALTH SERVICES - Washington (Perio) 2009 10/05/2009 Delta of AZ (GP & SP) 2.2016 07/16/2016 Delta of AZ (GP & SP) 2013 09/13/2013 Delta of AZ (GP & SP) 2017 02/07/2017 Delta of AZ (GP & Specialty) 2015 03/09/2015 Delta of AZ (GP & Specialty) PPO. Premier 03/2021 03/05/2021 DELTA OF CALIFORNIA PPO 10/12/2009 DELTA OF COLORADO - (Credentialing Application) 01/29/1903 Delta of Kansas (GP & Specialty) 2012 10/11/2012 Delta of Kansas (GP & Specialty) 2024 08/06/2024 Delta of KS 5.2018 05/16/2018 Delta of Nevada (GP & Specialty) 9.2013 09/18/2013 Delta of Nevada 2016 01/24/2016 Delta of Nevada 2017 03/29/2017 Delta of NV (GP & Specialty) 2014 03/18/2014 Delta of NV (GP & Specialty) PPO. Premier. Medicaid 2020 08/11/2021 Delta of OK (GP) 3.2014 12/16/2014 Delta of OK (SP) 3.2014 03/18/2014 Delta of OK Premier, PPO (GP) 2013 09/18/2013 Delta of Oklahoma (GP) 2015 02/07/2015 DELTA PPO - MD 06/25/2010 Delta PPO app/agrmt (specialist) MI state 03/24/2017 Delta Premier & DPO Full App (Texas) 05/28/2015 DELTA PREMIER - MD 06/25/2010 Delta Premier Only Full App (Texas) 05/28/2015 DELTA SELECT (Tricare Retiree Program) 10/07/2009 DELTA TIN REQUEST - MD 06/25/2010 DELTA USA - (Tricare Retiree) 01/05/2012 DELTACARE - (General) 04/09/2012 DeltaCare Application - (Georgia) 08/31/2012 DeltaCare Facility Form - Georgia 08/14/2012 DeltaCare USA - CA 09.2022 09/13/2022 DELTACARE USA - Washington (General/Specialist) 2009 10/05/2009 DeltaCare USA AZ (GP & SP) 2013 09/26/2013 DeltaCare USA CA (GP & SP) 2013 10/08/2013 DeltaCare USA HI 2014 10/28/2014 DELTACARE USA PMI - NCA 2009 (Orthodontist) 10/22/2009 DELTACARE USA PMI - NCA 2009 (Specialist) 10/22/2009 Deltacare USA-GP_SP-PA-NJ 2012 02/21/2012 DELTAGUARD PREFERRED - TX,FL,CA,NJ,NY Revsied 2009 10/05/2009 Dentacheck - VA 08/18/2011 Dentachek (General) - MD 08/18/2011 Dentachek (Specialist) - MD 08/18/2011 DENTACHEK - Maryland DENTAL DIRECTORY SERVICES - Arizona (General/Specialty) 10/08/2009 DENTAL BENEFIT PROVIDER - (HMO) Facilty Application 06/29/2011 DENTAL BENEFIT PROVIDER - (PPO) Facilty Application 05/25/2010 DENTAL BENEFIT PROVIDER - (Specialty) Facilty Application 05/25/2010 DENTAL BENEFIT PROVIDER - Oklahoma 07/22/2011 DENTAL BENEFIT PROVIDERS (Add Form) 2008 10/05/2009 DENTAL BENEFIT PROVIDERS (Add Form) 2009 10/05/2009 DENTAL BENEFIT PROVIDERS (National Agreement) 02/23/2012 Dental Benefit Providers (UHC) - 2020 05/26/2020 DENTAL BENEFIT PROVIDERS - (General/Specialist) 08/2010 08/23/2010 DENTAL BENEFIT PROVIDERS - (Recred) 12/18/1902 DENTAL BENEFIT PROVIDERS - All States Except California (General) 10/08/2009 DENTAL BENEFIT PROVIDERS - Arkansas 05/13/2011 DENTAL BENEFIT PROVIDERS - CA (General) 05/16/2011 DENTAL BENEFIT PROVIDERS - CA (Ortho / Specialty) 05/17/2011 Dental Benefit Providers - CA 2020 05/26/2020 DENTAL BENEFIT PROVIDERS - CA, NV Add Form 2011 (Interdent Use Only) 09/21/2011 DENTAL BENEFIT PROVIDERS - California (General Associate) 08/2010 08/20/2010 DENTAL BENEFIT PROVIDERS - California (Owner) 02/2009 10/15/2009 DENTAL BENEFIT PROVIDERS - California (Specialist) 10/22/2009 DENTAL BENEFIT PROVIDERS - California (Specialist) 02/2009 10/15/2009 DENTAL BENEFIT PROVIDERS - Colorado (General) 10/24/1902 DENTAL BENEFIT PROVIDERS - Colorado (Specialist) 04/08/1902 DENTAL BENEFIT PROVIDERS - N.CA (Additional Location) 10/14/2010 DENTAL BENEFIT PROVIDERS - NCA (Add Form) 03/22/2010 DENTAL BENEFIT PROVIDERS - NCA (GP) 03/22/2010 DENTAL BENEFIT PROVIDERS - NCA (Owner) 03/22/2010 DENTAL BENEFIT PROVIDERS - NCA (SP) 03/22/2010 DENTAL BENEFIT PROVIDERS - NCA Application 10/14/2010 DENTAL BENEFIT PROVIDERS - Ohio (General) 05/06/1902 DENTAL BENEFIT PROVIDERS - OR (2009) 08/31/2010 Dental Benefit Providers - OR - 2020 05/26/2020 DENTAL BENEFIT PROVIDERS - Southern California (General) 07/01/1902 DENTAL BENEFIT PROVIDERS - Southern California (Specialist) 10/23/2009 DENTAL BENEFIT PROVIDERS - Tennessee (Credentialing Form/Revised 2006) 07/08/1902 DENTAL BENEFIT PROVIDERS - Texas (General) 10/24/1902 DENTAL BENEFIT PROVIDERS - W. Texas 10/10/1902 DENTAL BENEFIT PROVIDERS - Washington 10/05/2009 DENTAL BENEFIT PROVIDERS / NPD - Texas 10/07/2010 Dental Benefit Providers AZ 4.2017 04/17/2017 Dental Benefit Providers AZ 5.2016 05/24/2016 Dental Benefit Providers AZ only (GP & SP) 7.2016 07/23/2016 DENTAL BENEFIT PROVIDERS DHMO & PPO - California (Primary Dentist Agreement) 10/05/2009 DENTAL BENEFIT PROVIDERS PPO - W. Texas 01/09/1902 Dental Benefit Providers/UHC - Additional Location CA - Interdent Use Only 10/08/2011 DENTAL CARE ADVANTAGE (General/Specialist) - Arizona 03/15/1902 Dental Care Plus - Dayton - North Vernon - Lawrenceburg 09/20/2012 DENTAL CARE PLUS - Ohio 01/15/1902 DENTAL DIRECTOR SERVICES - Arizona (GP & SP) 11/24/2009 Dental Directory Service Application - (Georgia) 06/21/2012 DENTAL DIRECTORY SERVICES - Colorado 05/03/1902 Dental Directory Services - OH 09/20/2012 DENTAL HEALTH ALLIANCE - (Facility Application) 04/20/2010 DENTAL HEALTH ALLIANCE - (General / Specialist) 2009 05/13/2011 DENTAL HEALTH ALLIANCE - (General / Specialist) 2011 06/11/2012 DENTAL HEALTH ALLIANCE - (General/Specialist) 02/23/2012 Dental Health Alliance - (General/Specialist) 2012 10/25/2012 DENTAL HEALTH ALLIANCE - Oklahoma 05/05/2011 DENTAL HEALTH ALLIANCE - Texas (General/Specialist) 12/15/2011 DENTAL HEALTH ALLIANCE - TN (Genral / Specialist) 2009 05/24/2011 DENTAL HEALTH ALLIANCE / ASSURANT EMPLOYEE BENEFITS 08/04/1902 DENTAl HEALTH ALLIANCE PPO - (General/Specialist) 10/14/2009 DENTAL HEALTH ALLIANCE PPO - OR/WA/NCA (General) 2009 10/20/2009 DENTAL HEALTH ALLIANCE PPO - Southern California (General & Specialty) 10/08/2009 DENTAL HEALTH SERVICES (Associate/Owner) - Northern California 05/07/1903 DENTAL HEALTH SERVICES (General/Specialist) 07/01/2009 10/08/2011 DENTAL HEALTH SERVICES (Orthodontist) - Northern California 05/07/1903 DENTAL HEALTH SERVICES (Specialist) - Northern California 05/07/1903 DENTAL HEALTH SERVICES - (All Speciality Except Ortho) 10/16/1901 DENTAL HEALTH SERVICES - (General) 10/15/1901 DENTAL HEALTH SERVICES - California (Associate General) Interdent 10/05/2009 DENTAL HEALTH SERVICES - California (Provider Information Sheet) * Dental Health Services - General Dentist 2020 06/16/2021 DENTAL HEALTH SERVICES - NCA (Endo) 2009 10/23/2009 DENTAL HEALTH SERVICES - NCA (General) 2009 10/26/2009 DENTAL HEALTH SERVICES - NCA (Ortho) 2009 10/23/2009 DENTAL HEALTH SERVICES - NCA (OS) 2009 10/23/2009 DENTAL HEALTH SERVICES - NCA (Pedo) 2009 10/23/2009 Dental Health Services - Ortho 2020 06/21/2021 DENTAL HEALTH SERVICES - SCA (Ortho) 2010 03/11/2010 Dental Health Services - Specialist 2020 06/21/2021 DENTAL HEALTH SERVICES - Washington (General) 2009 10/05/2009 DENTAL HEALTH SERVICES - Washington (General/Associate) DENTAL HEALTH SERVICES - Washington (General/Owner) Contract only * DENTAL HEALTH SERVICES - Washington (Oral Surgery) 2009 10/05/2009 DENTAL HEALTH SERVICES - Washington (Ortho) 2009 10/05/2009 DENTAL HEALTH SERVICES Specialist Oral Surgery 07-01-09 10/05/2009 DENTAL HEALTH SERVICES Specialist Ortho 07-01-09 10/05/2009 DENTAL HEALTH SERVICES Specialist Pedo 07-01-09 10/05/2009 DENTAL HEALTH SERVICES Specialist Perio 07-01-09 10/05/2009 DENTAL HEALTH SERVICES- (Facility Application) 04/20/2010 DENTAL NETWORK OF AMERICA - (Facility Application) 04/20/2010 DENTAL NETWORK OF AMERICA - (General/Speciallist) 12/15/1901 DENTAL NETWORK OF AMERICA - Arizona (Owner) 12/16/1901 DENTAL NETWORK OF AMERICA - BCBS of Oklahoma 08/05/2010 DENTAL NETWORK OF AMERICA - Colorado 09/10/1902 DENTAL NETWORK OF AMERICA - N. California 01/05/1903 DENTAL NETWORK OF AMERICA - Ohio 06/17/1902 DENTAL NETWORK OF AMERICA - Oklahoma (Owner) 05/25/2011 DENTAL NETWORK OF AMERICA - Oregon 11/01/1901 DENTAL NETWORK OF AMERICA - Southern California (Owner) 12/15/1901 DENTAL NETWORK OF AMERICA BC/BS - IL (Credential Application) 3-12-10 03/12/2010 DENTAL NETWORK OF AMERICA BC/BS - IL (Practice Application) 3-12-10 03/12/2010 DENTAL PREFERRED PROVIDER ORGANIZATION - Oregon * Dental Select Specialist (Texas) 05/28/2015 DENTAL WELLNESS PARTNERS - (Provider Application) 05/02/1902 DENTAL WELLNESS PARTNERS - FL / 2010 02/23/2012 DENTAL WELLNESS PARTNERS - OR / WA (General/Specialty) 2009 01/12/2010 Dental Wellness Partners Application - (Georgia) 04/16/2012 DentalSave (Update or Add Office) - Florida 08/08/2012 DENTALSOURCE - New Mexico * 01/05/2012 DENTAQUEST (DORAL) - NCA (2009) 01/04/2010 DENTAQUEST - MN (Application) 11/09/2010 DentaQuest - OH 09/20/2012 Dentaquest - STDA 09/18/2016 DENTAQUEST - Utah 2010 06/29/2010 DENTAQUEST - Virginia DENTAQUEST - WI (Application) 2010 11/09/2010 DENTAQUEST / DORAL - New Jersey (Specialist) 02/17/2011 DentaQuest 5.2016 05/23/2016 Dentaquest 6.2021 04/19/2022 DentaQuest Application-GA Medicaid - (Georgia) 09/12/2012 DentaQuest AZ 2012 06/21/2012 DENTAQUEST HMO - Maryland Dentaquest INN Full App 05/28/2015 Dentaquest Medi/CHIP - STDA 01/10/2013 DentaQuest Medicaid - So. TX 10/17/2011 Dentaquest Medicaid/CHIPS Texas 09/06/2012 Dentaquest OON Full App 06/02/2015 DENTAQUEST PPO & HMO Application DENTAQUEST PPO - Maryland DENTAQUEST PPO - MD 06/29/2010 DentaQuest PPO - VA 08/18/2011 Dentaquest~Fostercare/Attestation 2013/So.Tx 08/28/2012 Dentegra (GP & Spec) AZ, HI, KS, NV, OK, OR, WA 1.2017 09/21/2017 Dentegra (GP & Specialty) OR/WA/ AZ 2016 07/11/2017 DENTEGRA - California 04/20/1903 Dentegra - California - 09.2017 06/14/2018 DENTEGRA - OR & WA 10/05/2009 Dentegra 3.2020 03/11/2020 Dentegra All states 3.2024 03/25/2024 Dentegra Application - (Georgia) 05/04/2013 DENTEGRA-FL 01/23/2013 DENTEMAX 04/13/2011 Dentemax (GP & SP) 12.14 12/18/2014 DENTEMAX - Arkansas 05/13/2011 DENTEMAX - Oklahoma 05/05/2011 DENTEMAX - Southern California/Arizona (General/Specialist) 05/11/1902 Dentemax 11.15 12/12/2015 Dentemax 11.2015 11/29/2015 Dentemax 2023 09/14/2023 Dentemax app/agrmt (specialist) KS state 01/13/2017 DENTEMAX APPLICATION - (General/Specialist) 10/05/2009 Dentemax Application - (Georgia) 08/31/2012 Dentemax HI 2014 10/28/2014 DenteMax OR/WA (General/Specialist) 2009 10/05/2009 DENTEMAX RECREDENTIALING APPLICATION - NCA 2009 12/04/2009 DenteMax, DNOA, BCBSOK Combined App 8.2023 08/17/2023 DENTI CAL - (General / Specialist) eff. 2008 10/13/2009 DENTI-CAL - (Facility Application) 04/22/2010 DENTI-CAL DIRECT DEPOSIT FORM - (Facility Application) 04/20/2010 DENTICAL ADD LOCATION - DMD 05/21/2010 DENTISTAT 01/02/1903 DENTISTAT - 2011 04/18/2011 Dentistat app/agrmt (specialist) MI state 03/26/2017 Dentistat Application - (Georgia) 02/29/2012 Dentistat Dental app/agrmt (specialist) 03/15/2017 Dentistat/IDOA-FL 01/27/2012 DHA - Dayton - Indiana 09/20/2012 DHA - FL 12/02/2010 DHA / ASSURANT - CA (All) 04/21/2011 DHA Application - (Georgia) 09/17/2012 DHA PPO Existing Provider Form 10/05/2009 DHA recred - STDA 10/02/2017 DHA/Dental Health Alliance - STDA 08/23/2013 01/21/2014 DHS APPLICATION w/ LAP - DMD 05/21/2010 DHS Orthodontic Specialty Agreement 07/09 10/05/2009 DHS-Southern California (GP/SP) application 07/09 10/05/2009 DIVERSIFIED DENTAL - (Credentialing Application) 01/29/2010 DIVERSIFIED DENTAL - Reno (North) 04/16/2012 DIVERSIFIED DENTAL - Vegas (South) 04/16/2012 Diversified Dental NV 12.2023 12/13/2023 Diversified Dental Services 2016 02/20/2016 DMBA - Utah 09/29/1902 DNOA (Texas) 06/02/2015 DNOA - Nevada (Owner) 11/08/1901 DNoA / BLUE CROSS BLUE SHIELD - (Credentialing App) 03/29/2010 DNoA Application - (Georgia) 08/31/2012 DNoA Practice Application - Georgia 08/08/2012 DNOA TX 102015 11/05/2015 DNoA/BCBS ~ TX 2011 07/25/2011 DNOA/BCBS TX - STDA 06/21/2018 Dominion Agreement - MD 08/05/2011 Dominion Dental (GP) PPO/DHMO-NJ 04/02/2013 Dominion Dental (SP) Ortho-DHMO-PA 04/02/2013 Dominion Dental (SP) Ortho-NJ 04/02/2013 Dominion Dental (SP)-OS/Perio PPO/DHMO-NJ 04/02/2013 Dominion Dental SP-(OS&Perio) PPO/DHMO-PA 04/02/2013 Dominion PPO/DMO (General) - VA 10/20/2011 DORAL DENTAL USA - Massachusetts 02/21/1903 DORAL PROVIDER APPLICATION 10/05/2009 EDS & Principal AZ (GP & SP) 2013 09/16/2013 EDS & Principal AZ 2012 (GP & Specialty) 10/11/2012 EDUCATORS MUTUAL - Utah (General) 02/19/2010 EDUCATORS MUTUAL - Utah (Ortho) 02/19/2010 EDUCATORS MUTUAL - Utah (Specialist) 02/19/2010 EMPIRE BLUE CROSS / BLUE SHIELD - New Jersey (Specialist) 02/17/2011 EMPLOYEE DENTAL SERVICES (Specialty) 10/05/2009 EMPLOYEE DENTAL SERVICES - Arizona (General) 10/05/2009 EMPLOYERS DENTAL SERVICE - Arizona (General) Revised 2009 10/05/2009 Express Dental - TX (GP & SPC) 01/23/2012 Express Dental Care Application - (Georgia) 01/30/2012 Express Dental So. TX 07/27/2012 FCL (First Continental & Life) KS (GP & SP) 2016 09/12/2018 FCL - STARDENT - Texas 10/22/2009 FCL - STDA 09/19/2012 FCL - Texas - Add Location Form 09/19/2012 FCL - Texas - Recredentialing Application 09/19/2012 FCL / PDP - TX 06/28/2011 FCL KS (GP & SP) 2013 09/21/2013 FCL recred - STDA 07/06/2018 FCL STARDENT - Texas (General/Specialist) 04/25/2011 FCL TX - STDA 08/23/2013 08/26/2013 FCL/PDP ~ TX 2011 ~ South Texas Dental 09/01/2011 FCL/PDP ~ TX 2012 07/06/2012 FCL/PDP~TX 2012 02/07/2013 FDH (GP & SP) NV 12.14 07/15/2015 FDH (GP & SP) NV 4.2013 07/19/2014 FDH AZ (GP & SP) 12.14 12/18/2014 FDH AZ (GP & SP) 4.2013 07/19/2014 Fidelio PPO-GP/SP (PA/NJ) 04/02/2013 FIRST DENTAL HEALTH (General/Specialist) 2008 10/05/2009 First Dental Health (GP & SP) AZ 10.2017 10/26/2017 First Dental Health (GP & Specialty) NV 2012 10/11/2012 FIRST DENTAL HEALTH - (GP/SP) revised 1/1/2011 01/04/2011 FIRST DENTAL HEALTH - CA (Add Loc Form) 04/25/2011 First Dental Health - California (General & Specialist) 12/2014 12/18/2014 First Dental Health - California (General/Specialist) 07/2014 11/19/2014 FIRST DENTAL HEALTH - NV (GP/SP) revised 04/2011 09/19/2011 FIRST DENTAL HEALTH - Southern California (General/Specialist) 10/05/2009 FIRST DENTAL HEALTH = (GP/SP) revised 04/2011 09/16/2011 First Dental Health AZ (GP & SP) 10/13/2015 First Dental Health Existing Provider Form 05/28/2010 First Dental Heath (General & Specialist) 2016 - CA 01/24/2016 FIRST DENTAL NETWORK - California 2009 09/11/1902 FL GD Access Dental (2012) 03/12/2012 FL GD Advantica 08/27/2012 FL GD Aetna (2012) 02/06/2013 FL GD AHCA Medicaid (2012) 06/11/2013 FL GD American Dental Network (2012) 03/12/2012 FL GD Ameriplan (2012) 06/07/2012 FL GD Ameritas (2012) 03/12/2012 FL GD Argus (2012) 11/15/2012 FL GD Assurant (2012) 08/31/2012 FL GD Careington (2012) 09/20/2012 FL GD Cigna (2012) 03/12/2012 FL GD Connection-GEHA (2012) 09/12/2012 FL GD Cover Sheet (2012) 03/12/2012 FL GD DeCare (2012) 03/12/2012 FL GD DeCare (Updated) 2012 05/17/2012 FL GD Delta Care USA (2012) 08/31/2012 FL GD Delta Dental (2012) 08/31/2012 FL GD Dental Directory Services (2012) 03/12/2012 FL GD Dental Save (2012) 06/28/2012 FL GD DentaQuest (2012) 07/13/2013 FL GD Dentegra (2012) 11/16/2012 FL GD Dentemax (2012) 03/12/2012 FL GD DHA (2012) 09/20/2012 FL GD DNoA (2012) 03/12/2012 FL GD DXC (2012) 03/12/2012 FL GD Eatles Benefits by Disign (2012) 03/12/2012 FL GD Express Dental (2012) 03/12/2012 FL GD First Continental Life (2012) 07/24/2012 FL GD Florida Combined Life (2012) 06/21/2012 FL GD Florida Dental Benefits (2012) 03/12/2012 FL GD Guardian-MDG (2012) 07/30/2012 FL GD Humana (2012) 10/08/2012 FL GD IDOA (2012) 03/12/2012 FL GD Logistic Health (2012) 07/24/2012 FL GD Logistics (2012) 06/07/2012 FL GD Master App (2012) 03/12/2012 FL GD Maverest Dental Network (2012) 07/24/2012 FL GD MCNA (2012) 07/12/2013 FL GD MetLife (2012) 03/12/2012 FL GD Premier Dental (2012) 10/17/2012 FL GD Principal (2012) 03/12/2012 FL GD Project HERO (2012) 03/12/2012 FL GD Safeguard (2012) 08/31/2012 FL GD Sefeguard (2012) 03/12/2012 FL GD Signature Dental (2012) 06/28/2012 FL GD Solstice (2012) 05/28/2012 FL GD UCCI (2012) 08/31/2012 FL GD UHC (2012) 03/12/2012 FL GD Uni-Care (2012) 03/12/2012 FL GD WellPoint (2012) 04/26/2013 FL Spec Access Dental (2012) 03/15/2012 FL Spec ADN (2012) 03/15/2012 FL Spec Advantica (2012) 08/27/2012 FL Spec Aetna PPO - DMO (2012) 02/06/2013 FL Spec AHCA Medicaid (2012) 11/15/2012 FL Spec Ameriplan USA (2012) 03/15/2012 FL Spec Ameritas (2012) 03/15/2012 FL Spec Argus (2012) 11/15/2012 FL Spec Assurant (2012) 06/06/2012 FL Spec Assurant DMO (2012) 06/11/2012 FL Spec Careington (2012) 09/20/2012 FL Spec DeCare (Updated) 2012 05/17/2012 FL Spec Delta Care USA (2012) 07/24/2012 FL Spec Delta Dental (2012) 07/24/2012 FL Spec Dentegra (2012) 11/16/2012 FL Spec Dentemax (2012) 03/15/2012 FL Spec DHA-PPO (2012) 09/20/2012 FL Spec DNoA (2012) 03/15/2012 FL Spec DXC Medicaid Enrollment Form (2012) 03/15/2012 FL Spec Eagles Benefits (2012) 03/15/2012 FL Spec Express Dental (2012) 03/15/2012 FL Spec First Continental Life (2012) 03/15/2012 FL Spec Florida Combined Life (2012) 06/21/2012 FL Spec Florida Dental Benefits (2012) 03/15/2012 FL Spec Guardian-MDG (2012) 06/06/2012 FL Spec Humana (2012) 10/08/2012 FL Spec IDOA-Dentistat (2012) 03/15/2012 FL Spec Master App (2012) 03/15/2012 FL Spec MCNA (2012) 08/16/2012 FL Spec MetLife (2012) 03/15/2012 FL Spec Principal (2012) 03/15/2012 FL Spec Project HERO (2012) 03/15/2012 FL Spec Safeguard (2012) 04/26/2013 FL Spec Signature Dental Plan (2012) 03/15/2012 FL Spec Solstice (2012) 05/28/2012 FL Spec UCCI (2012) 06/07/2012 FL Spec Uni-Care (2012) 03/15/2012 FL Spec United Health Care (2012) 03/15/2012 FL Spec WellPoint Dental (2012) 08/08/2012 FLC / ORAQUEST - TN (General / Specialist) 2011 05/25/2011 FLC / ORAQUEST - TX (General / Specialist) 2011 04/25/2011 Florida Credentialling 07/22/2011 Florida Dental Benefits (Practice Information Form) 08/08/2012 FORTIS 03/24/1902 FORTIS - Arizona 10/07/2009 FORTIS HMO - Oklahoma (Associate) Interdent 10/05/2009 FOSTER CARE PROGRAM / DELTA DENTAL - TX 04/30/2010 FOUNDATION DENTAL - Arizona (General) FOUNDATION HEALTH SYSTEMS (General/Specialist) FOURSTAR - Arizona (General) 10/08/2009 FOURSTAR - Arizona (Specialist) 04/26/1902 GE FINANCIAL - Arizona (General) Signature Dental App 10/05/2009 GE FINANCIAL - Arizona (Specialist) Signature Dental App 10/05/2009 GE FINANCIAL - California (General/Specialist) Form 050184B 04/21/1902 GE FINANCIAL - Nevada (General/Specialist) Form 050184B 04/22/1902 GE FINANCIAL - New Mexico (General) Signature Dental Application GE FINANCIAL - Oregon (General) Signature Dental Application GE FINANCIAL - Preferred Dental Network Application 10/07/2009 GE FINANCIAL - Washington (General) Signature Dental Application GE SIGNATURE DENTAL PLAN - (GP & SP) Updated Agreement 06/2012 06/08/2012 GE SIGNATURE DENTAL PLAN - AZ/OR/WA/CO (General/Specialist) 10/09/2009 GE SIGNATURE FINANCIAL - (Add Location Form) 01/15/2010 GEHA - CONNECTION DENTAL PARTICIPATING PROVIDER AGREEMENT - 3-12-10 03/12/2010 GEHA - CONNECTION DENTAL PROVIDER APPLICATION - 3-12-10 03/12/2010 GEHA - STDA 11/05/2012 GEHA / CONNECTION DENTAL 03/08/2010 GEHA Application - (Georgia) 07/13/2013 GEHA TX - STDA 08/23/2013 08/27/2013 GOLDEN WEST - (General) 05/06/2011 GOLDEN WEST - (Ortho) 05/06/2011 GOLDEN WEST - (Specialist) 05/06/2011 GOLDEN WEST DENTAL (Associate Dentist) * GOLDEN WEST DENTAL (Endodontist) GOLDEN WEST DENTAL (Oral Surgery) GOLDEN WEST DENTAL (Orthodontist) GOLDEN WEST DENTAL (Periodontist) GOLDEN WEST DENTAL - (Pedodontist) 02/03/2011 Golden West HMO (General Dentist) 09/04/2015 Golden West HMO (Ortho) 09/04/2015 Golden West HMO (Specialty) 09/04/2015 GROUP HEALTH - WI (Dental) 11-2010 11/09/2010 Guardian (Texas) 06/02/2015 Guardian - Dayton 09/20/2012 Guardian - Indiana 09/20/2012 GUARDIAN - Oklahoma 05/05/2011 GUARDIAN - OR/WA (General/Specialist) 2009 10/20/2009 GUARDIAN / MDC CBO - So Cal (Facility Application) 08/30/2010 GUARDIAN / MDC CBO - So Cal (GP New / Add Location) 08/30/2010 GUARDIAN AGREEMENT - MD 07/02/2010 Guardian app/agrmt (specialist) MI state 03/26/2017 Guardian Application - (Georgia) 06/07/2012 GUARDIAN APPLICATION - VA 06/24/2010 GUARDIAN DHMO / PPO - FL 02/23/2012 GUARDIAN DHMO / PPO - Texas 08/18/2011 GUARDIAN HMO & PPO - CA,FL,NJ,NY,TX 2009 12/06/2010 GUARDIAN HMO / MANAGED DENTAl GUARD - Associate (General/Specialist) 12/02/2009 GUARDIAN HMO / MANAGED DENTAL GUARD - Associate (General/Specialist) So. Texas 11/05/2009 GUARDIAN HMO / MANAGED DENTAL GUARD - S. CA (General) Interdent 02/01/2011 GUARDIAN HMO / MANAGED DENTALGUARD - Northern California (General) GUARDIAN HMO/MANAGED DENTAL GUARD - California (Specialist) 10/05/2009 GUARDIAN HMO/MANAGED DENTAL GUARD - NCA 2011 (General) 01/25/2014 GUARDIAN HMO/MANAGED DENTAL GUARD - SCA 2011 (General) 01/25/2014 Guardian PPO app/agrmt KS state 01/20/2017 GUARDIAN PPO & DHMO / MANAGED DENTAL GUARD - Southern California (General) 10/28/2009 GUARDIAN PPO & DHMO / MANAGED DENTAL GUARD - Southern California (Specialist) 10/08/2009 GUARDIAN PPO & DHMO MANAGED DENTAL GUARD - California (General) 10/13/2009 Guardian PPO & HMO - STDA 01/12/2017 Guardian PPO (PA) 2011 08/04/2011 GUARDIAN PPO - (Add Location) 04/20/2011 GUARDIAN PPO - (General/Specialist) DentalGuard Preferred Network 10/13/2009 GUARDIAN PPO - (General/Specialist) Revised 2009 10/05/2009 GUARDIAN PPO - Arizona (GP & SP) Managed Dental Guard Preferred Network 10/09/2009 GUARDIAN PPO - Arkansas 09/07/2011 GUARDIAN PPO - Colorado 11/09/1902 GUARDIAN PPO - MD (Application/Agreement) rev 01/09 08/26/2010 Guardian PPO - Texas - Add Location Form 09/19/2012 Guardian PPO - VA 08/04/2011 GUARDIAN PPO - WA & OR (General/Specialist) 2009 10/13/2009 GUARDIAN PPO / DMO - So. TX (General / Specialist) 2012 11/06/2012 Guardian PPO 01.2021 - CA 07/24/2021 Guardian PPO 04.2020 - AZ, HI, OK 8.24.2021 08/27/2021 Guardian PPO 04.2020 - KS 05/26/2020 Guardian PPO 04.2020 - NV 05/26/2020 Guardian PPO 04.2020 - OR 05/26/2020 Guardian PPO 04.2020 - WA 05/26/2020 Guardian PPO 06.2019 - AZ, HI, OK 07/05/2019 Guardian PPO 06.2019 - AZ, HI, OK 07/05/2019 Guardian PPO 12.2015- OR 01/23/2016 Guardian PPO 12.2015- WA 01/23/2016 Guardian PPO 2014 10/26/2014 GUARDIAN PPO AGREEMENT - VA 06/24/2010 Guardian PPO CA 2014 10/26/2014 GUARDIAN PPO Dental Guard Network (General/Specialist) - InterDent use only 08/13/2011 Guardian Update form- 10/15 10/31/2015 Guardian/Avesis - AZ Medicaid 5.1.2019 05/02/2019 HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - New Hampshire HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - Rhode Island HAWAII DENTAL SERVICE 07/16/2010 HDS HI 2015 01/07/2017 HEALTH CHOICE - OK 03/28/2011 Health Choice OK 9.2013 09/19/2013 HEALTH NOW - New York (General/Specialist) HEALTH NOW - New York (General/Specialist) Ontario Region HEALTH NOW - New York (General/Specialist) Syracuse / Utica Region HEALTH PARTNERS 02/03/1903 HEALTH PARTNERS DENTAL (Inital Credentialing) 10/05/2009 Health Resources - Indiana 09/20/2012 Health Spring (TN) 09/15/2011 HealthChoice OK 07/2024 9/30/2024 09/30/2024 HealthChoice OK 2014 12/16/2014 HEALTHFIRST HEALTHNET DENTAL 10/07/2009 HealthSmart (GP & SP) 9.2013 09/12/2013 HealthSmart (GP & Spec) NV 09.2017 09/28/2017 HealthSmart (GP & Specialist) 08.2018 - CA 08/17/2018 HealthSmart (GP & Specialty) 2012 06/25/2012 HMAA - HI 07/16/2010 HMAA HI 2014 10/30/2014 HMSA BC/BS - HI 07/16/2010 HMSA HI 2014 10/30/2014 HMWG-HMAA HI 11.2020 11/19/2020 Horizon - NJ 08/10/2011 Horizon - PA 08/09/2011 HP Application-GA Medicaid- (Georgia) 03/06/2012 HP Enterprise NV Medicaid 09.2017 03/06/2018 HUMAN DENTAL - PA & NJ 05/13/2011 HUMANA - FL 02/23/2012 Humana - OK 04/27/2023 HUMANA - Oklahoma 11/08/2011 HUMANA - OR/WA (General/Specialist) 2009 10/23/2009 HUMANA - So TX & TN (Recred App) 04/25/2011 HUMANA - SoCal (General) 04/01/1902 HUMANA - SoCal (Specialist) 04/02/1902 HUMANA / COMPBENEFITS - So.TX & TN (General/Specialist) - 2012 09/25/2012 Humana all states but CA 8.2024 08/09/2024 Humana Application - (Georgia) 07/11/2013 HUMANA APPLICATION - MD 06/24/2010 HUMANA APPLICATION - VA 06/24/2010 HUMANA APPLICATION - WI 10/29/2010 HUMANA DENTAL 10/27/2009 HUMANA DENTAL - Arkansas 05/16/2011 HUMANA DENTAL - NCA 2009 10/16/2009 Humana Dental PPO - 2012 01/25/2014 HUMANA DENTAL PPO - Southern California 10/08/2009 Humana of CA (GP & Specialty) 8/.2024 08/09/2024 HUMANA PPO (Specialist) 2008 10/05/2009 Humana PPO - recredentialing app STDA 06/15/2018 HUMANA PPO - STDA 09/19/2012 Humana PPO - TX STDA 03/04/2019 Humana PPO - VA 08/04/2011 Humana PPO 10.2018 04/02/2019 Humana PPO 2014 03/17/2014 Humana PPO 2015 02/25/2015 Humana PPO HI 2014 10/30/2014 Humana PPO OK (GP & Specialty) 10.2018 11/21/2018 HUMANA PPO WORK HISTORY - VA 06/24/2010 Humana Recredentialing 09/13/2012 Humana Service Agreement - MD 08/04/2011 Humana Specialty Benefits - Texas - Recredentialing Application 09/19/2012 Humana/Compbenefits-FL 10/17/2012 INSURANCE DENTISTS OF AMERICA (IDOA) 07/05/2012 INTERPLAN - (Associate Dentist) NCA 2009 10/16/2009 INTERPLAN - So. California (Associate General/Specialist) 10/14/2009 Interplant Existing Provider Form 10/05/2009 JPS HEALTH NETWORK - Texas 10/05/2009 KEMPER PREFERRED PROVIDER NETWORK LABOR & INDUSTRY - WA (General & Specialty) BN!D / 2011 03/15/2011 LABOR & INDUSTRY - Washington 08/13/1902 LABOR & INDUSTRY - Washington (General/Specialist) 2009 10/05/2009 LABORERS HEALTH & WELFARE TRUST - Southern California Liberty CA 4.2023 04/27/2023 LIBERTY DENTAL - (Provider App) 12 / 2010 03/31/2011 LIBERTY DENTAL - CA (All) 05/06/2011 LIBERTY DENTAL - FL 02/27/2012 LIBERTY DENTAL - Owner (GP) 05/02/1902 LIBERTY DENTAL - Provider Application 02/16/2010 LIBERTY DENTAL - Specialties 05/07/1902 LIBERTY DENTAL - Texas 05/19/2013 Liberty Dental - Texas (Owner) 08/20/2011 Liberty Dental CA (General) 2014 06/25/2014 Liberty Dental CA (Specialty-Ortho) 11.2018 04/12/2019 Liberty Dental CA (Specialty/Ortho) 2014 06/25/2014 LIBERTY DENTAL DHMO - (Revised) 03/20/1902 LIBERTY DENTAL PLAN (General) 10/05/2009 LIBERTY DENTAL PLAN - California 03/31/1903 LIBERTY DENTAL PLAN - California (GP) 07/25/1902 LIBERTY DENTAL PLAN - Nevada (GP) 07/26/1902 LIBERTY DENTAL PLAN APPLICATION - 09/2009 10/05/2009 LIBERTY DENTAL PLAN APPLICATION - 2010 07/13/2010 LIBERTY DENTAL PLAN PPO 04/02/1903 LIBERTY DENTAL PROGRAM 09/03/1902 Liberty Dental-Fac TX Owner 2012 06/23/2012 Liberty HI & AZ 9/2/2016 01/05/2018 Liberty HI 2014 11/05/2014 LIBERTY MASTER AGREEMENT - DMD 05/20/2010 LNI - WA. 9.27.2018 09/28/2018 Logistic Health - (Dental Facility Information Sheet) 08/13/2012 Logistics Health (application) 04/09/2012 LOGISTICS HEALTH (FEDS Health) 10/05/2009 MAHP CredApp INITIAL - FINAL 2006-06 10/04/2014 MAHP CredApp RECRED - FINAL 2006-06 10/05/2014 MANAGED DENTAL GUARD (Guardian HMO) - CA 09.2019 (General) 09/24/2019 MANAGED DENTAL GUARD (Guardian HMO) - CA 09.2019 (Specialty) 01/23/2020 MANAGED DENTAL GUARD - (Facility Application) 04/22/2010 Maryland Standard (State) Application 06/07/2013 MASS HEALTH (Group) Application 05/11/1902 MASS HEALTH (Individual) Application 05/10/1902 Maverest (GP & Specialty) 2014 07/08/2014 Maverest (Texas) 06/03/2015 Maverest - STDA - TX 12/26/2014 MAVEREST DENTAL ALLIANCE (Participating Dentist Application) 03/07/1902 MAVEREST DENTAL ALLIANCE - Arizona (General) 10/09/2009 MAVEREST DENTAL ALLIANCE - Tennessee 07/06/2012 Maverest Dental Network Application - (Georgia) 08/31/2012 Maverest PPO-GP/SP (NJ&PA) 03/31/2013 Maverest-FL 08/09/2012 MCNA - add loc request - STDA 07/18/2018 MCNA - FL 06/21/2013 MCNA - FL (Credentialing App & Specialist Contract) 09/30/2010 MCNA - STDA 07/18/2018 MCNA Exist Prov - STDA 11/30/2018 MCNA INN Full App 06/03/2015 MCNA Medicaid/CHIPS Texas 09/06/2012 MCNA OON Full App 06/03/2015 MCNA Re-Cred App - STDA 07/15/2015 MCNA ReCred - STDA 11/15/2017 MCNA So. TX 09/23/2011 MCNA So. TX 09/12/2011 MDG / GUARDIAN - CA (General) 05/17/2011 MDG / GUARDIAN - CA (Specialist) 05/17/2011 MedFocus Facility Application 04/15/2013 MedFocus Provider Sheet 04/15/2013 MedFocus Rules & Regulations Master 04/15/2013 Medica Clinic Facility Add Term Change Form 04/15/2013 Mercy Care AZ 2011 11/23/2011 MeritDent 5.2016 05/07/2016 MeritDent NV (GP) 2013 09/13/2013 Met Life � CA 6.2025 07/03/2025 Met Life � OR 6.2025 07/03/2025 Met Life � WA 6.2025 07/08/2025 Met Life CA 2023 04/05/2023 Met Life NV 10.2024 10/15/2024 Met Life OK 10.2024 10/18/2024 Met Life Standard HI, KS 10.2024 10/15/2024 Met Life WA 10.2024 10/16/2024 Metlife (Texas) 06/03/2015 METLIFE - Florida 02/23/2012 MetLife - NJ 08/10/2011 METLIFE - NV (General & Specialty) 2011 05/05/2011 MetLife - OH & Indiana 09/20/2012 METLIFE - Oklahoma 05/05/2011 METLIFE - Oregon (General/Specialist) 2009 10/22/2009 METLIFE - Washington (General/Specialist) 2009 10/22/2009 MetLife 2016 01/24/2016 Metlife app/agrmt (specialist) MI state 03/27/2017 Metlife Application - (Georgia) 08/31/2012 MetLife AZ 4/15/2025 04/17/2025 MetLife AZ 7.2023 07/22/2023 MetLife COMPLETE NV App Booklet 090321 10/05/2023 METLIFE DENTAL - (GP/SP) 2009 10/05/2009 METLIFE DENTAL - Arkansas 05/16/2011 METLIFE DENTAL - NCA (General/Specialist) 2009 10/16/2009 METLIFE DENTAL PPO (General/Specialist) 02/15/2016 METLIFE DENTAL PPO (General/Specialist) Application Only 10/05/2009 METLIFE DENTAL PPO - SCA (General) 10/05/2009 METLIFE DENTAL PPO - SCA (Specialist) 10/05/2009 Metlife HI 2014 11/06/2014 MetLife HI 2016 01/24/2016 MetLife NV 2016 01/24/2016 MetLife OK 2023 10/06/2023 MetLife OR (GP & SP) 7.15. 07/15/2015 MetLife OR 2015 07/15/2015 MetLife OR 2022 11/14/2022 METLIFE PDP 05/06/2011 METLIFE PDP (California Addendum) 10/05/2009 METLIFE PDP (PPO) 10/31/2015 METLIFE PDP - MD 07/09/2010 METLIFE PDP - VA 07/08/2010 MetLife PDP Updated form-10/15 10/31/2015 Metlife PPO (MD) 2011 07/23/2011 Metlife PPO (NJ) 2011 07/23/2011 Metlife PPO (PA & VA) 2011 07/23/2011 METLIFE PPO - Washington 06/21/2012 MetLife WA 2015 07/15/2015 MetLife WA 2022 02/10/2022 MI GD GEDC ADN App (2012) 06/11/2012 MI GD GEDC Aetna PPO-DMO App (2012) 06/11/2012 MI GD GEDC Ameritas App (2012) 06/11/2012 MI GD GEDC Assurant DMO App (2012) 06/11/2012 MI GD GEDC BCBS App (2012) 06/11/2012 MI GD GEDC Careington App (2012) 09/20/2012 MI GD GEDC Cigna PPO-DHMO App (2012) 06/11/2012 MI GD GEDC DeCare App (Updated 2012) 06/11/2012 MI GD GEDC Delta Care USA (Updated 2012) 09/17/2012 MI GD GEDC Delta Dental PPO-Premier App (2012) 06/11/2012 MI GD GEDC DeltaCare USA App (2012) 06/11/2012 MI GD GEDC DenCap App (2012) 06/11/2012 MI GD GEDC Dental Directory App (2012) 06/11/2012 MI GD GEDC Dental Wellness App (2012) 06/11/2012 MI GD GEDC Dentemax App (2012) 06/11/2012 MI GD GEDC DHA App (2012) 06/11/2012 MI GD GEDC First Commonwealth App (2012) 06/11/2012 MI GD GEDC GEHA App (2012) 06/26/2012 MI GD GEDC Golden App (2012) 06/11/2012 MI GD GEDC Guardian App (2012) 06/11/2012 MI GD GEDC Humana App (2012) 09/20/2012 MI GD GEDC IDOA App (2012) 06/11/2012 MI GD GEDC Master App (2012) 06/11/2012 MI GD GEDC Maverest App (2012) 07/25/2012 MI GD GEDC MDP App (2012) 06/11/2012 MI GD GEDC MetLife App (2012) 06/11/2012 MI GD GEDC New Provider Activation (2012) 06/11/2012 MI GD GEDC New Provider check-off log (2012) 06/11/2012 MI GD GEDC Principal App (2012) 06/11/2012 MI GD GEDC Superior App (2012) 06/11/2012 MI GD GEDC UCCI App (2012) 06/11/2012 MI GD GEDC UHC App (2012) 06/11/2012 MI GD GEDC Uni-Care App (2012) 06/11/2012 MI GD GEDC WellPoint App (2012) 06/11/2012 MI GEDC GD DHA App (Updated 2012) 08/31/2012 MI GEDC Spec DHA App (Updated 2012) 08/31/2012 MI Spec GEDC ADN App (2012) 06/14/2012 MI Spec GEDC Aetna PPO and DHMO App (2012) 06/14/2012 MI Spec GEDC Ameritas App (2012) 06/14/2012 MI Spec GEDC Assurant App (2012) 06/14/2012 MI Spec GEDC BCBS App (2012) 06/14/2012 MI Spec GEDC Careington App (2012) 09/20/2012 MI Spec GEDC Cigna PPO and DHMO App (2012) 06/14/2012 MI Spec GEDC DeCare App (updated 2012) 06/14/2012 MI Spec GEDC Delta Care USA (Updated 2012) 09/17/2012 MI Spec GEDC Delta Care USA App (2012) 06/14/2012 MI Spec GEDC Delta Dental PPO and Premier App (2012) 06/14/2012 MI Spec GEDC DenCap App (2012) 06/14/2012 MI Spec GEDC Dental Directory (2012) 06/14/2012 MI Spec GEDC Dental Wellness App (2012) 06/14/2012 MI Spec GEDC Dentemax App (2012) 06/14/2012 MI Spec GEDC DHA App (2012) 06/14/2012 MI Spec GEDC First Commonwealth App (2012) 06/14/2012 MI Spec GEDC GEHA App (2012) 06/26/2012 MI Spec GEDC Golden App (2012) 06/14/2012 MI Spec GEDC Guardian App (2012) 06/14/2012 MI Spec GEDC Humana App (2012) 09/20/2012 MI Spec GEDC IDOA App (2012) 06/14/2012 MI Spec GEDC Master App (2012) 06/14/2012 MI Spec GEDC Maverest App (2012) 07/25/2012 MI Spec GEDC MDP App (2012) 06/14/2012 MI Spec GEDC MetLife App (2012) 06/14/2012 MI Spec GEDC New Provider Activation (2012) 06/14/2012 MI Spec GEDC New Provider check-off log (2012) 06/14/2012 MI Spec GEDC Principal App (2012) 06/14/2012 MI Spec GEDC Superior App (2012) 06/14/2012 MI Spec GEDC UCCI App (2012) 06/25/2012 MI Spec GEDC UHC App (2012) 06/25/2012 MI Spec GEDC Uni-Care App (2012) 06/25/2012 MI Spec GEDC WellPoint App (2012) 06/25/2012 MINNESOTA MEDICAL ASSISTANCE 2/2009 10/05/2009 MUTUALLY PREFERRED - Group Agreement Associate (General/Specialist) MUTUALLY PREFERRED - Group Agreement Owner - Colorado (General/Specialist) MUTUALLY PREFERRED - Individual Agreement (General/Specialist) NADP 2015 03/07/2015 NATIONAL DISCOUNT SERVICE - California * NATIONAL DISCOUNT SERVICE - Oregon 02/08/1902 NATIONAL DISCOUNT SERVICE - Washington 02/08/1902 NATIONAL DISCOUNT SERVICES - TN (General) 12/04/2009 NATIONAL HEALTH CARE DISCOUNT INC - Colorado (General) * NATIONAL HERITAGE INSURANCE COMPANY (Texas Medicaid) NATIONAL PACIFIC DENTAL - Out of Texas (Associate Dentist) NATIONAL PACIFIC DENTAL - Texas (Associate) NATIONAL PACIFIC DENTAL HMO - Texas (General) 10/25/1902 Nevada Long Form (State) 09.2017 10/04/2017 Nevada Short Form Addtl Loc 09.2017 10/04/2017 Nevada State Long Form 12.2016 08/17/2018 NEW - Cigna General PPO/DHMO - (Georgia) 06/11/2013 NEW - Cigna Specialty PPO/DHMO - (Georgia) 06/11/2013 NEW - FL GD AHCA Medicaid Location (2013) 06/11/2013 Newest FCL (First Continental Life) credentialing application 07/31/2013 NEWPORT DENTAL - NCA (General/Specialist) 2009 10/16/2009 NEWPORT DENTAL PLAN - (General/Specialty) 02/01/2011 NEWPORT DENTAL PLAN - Southern California (General) 10/08/2009 NJ GEDC Aetna App (2012) 08/08/2012 NJ GEDC Ameriplan USA App (2012) 08/08/2012 NJ GEDC Ameritas App (2012) 08/08/2012 NJ GEDC Careington App (2012) 09/20/2012 NJ GEDC DeCare App (2012) 08/08/2012 NJ GEDC Delta Dental App (2012) 08/08/2012 NJ GEDC DentaSave App (2012) 08/08/2012 NJ GEDC Dentemax App (2012) 08/08/2012 NJ GEDC DHA (Updated 2012) 08/31/2012 NJ GEDC DHA App (2012) 08/08/2012 NJ GEDC Empire App (2012) 08/08/2012 NJ GEDC GEHA App (2012) 08/08/2012 NJ GEDC Guardian App (2012) 08/08/2012 NJ GEDC Horizon App (2012) 08/08/2012 NJ GEDC IDOA App (2012) 08/08/2012 NJ GEDC LHI App (2012) 08/08/2012 NJ GEDC Master App (2012) 08/08/2012 NJ GEDC Maverest (2012) 08/08/2012 NJ GEDC MetLife App (2012) 08/08/2012 NJ GEDC Principal App (2012) 08/08/2012 NJ GEDC UCCI App (2012) 08/08/2012 NJ GEDC UHC App (2012) 08/08/2012 NY GEDC Aetna App (2012) 08/02/2012 NY GEDC Ameriplan USA App (2012) 08/02/2012 NY GEDC Ameritas App (2012) 08/02/2012 NY GEDC Careington App (2012) 09/20/2012 NY GEDC CSEA APP (2012) 08/06/2012 NY GEDC DeCare App (2012) 08/06/2012 NY GEDC Delta Care USA App (2012) 08/06/2012 NY GEDC Delta Dental App (Updated 2012) 08/28/2012 NY GEDC DentalSave App (2012) 08/06/2012 NY GEDC DentaQuest App (2012) 08/06/2012 NY GEDC Dentemax App (2012) 08/06/2012 NY GEDC DHA (Updated 2012) 08/31/2012 NY GEDC DHA App (2012) 09/20/2012 NY GEDC DNOA APP (2012) 08/28/2012 NY GEDC EDP App (2012) 08/06/2012 NY GEDC Empire App (2012) 08/08/2012 NY GEDC FitzHarris App (2012) 08/06/2012 NY GEDC GEHA App (2012) 08/08/2012 NY GEDC GHI App (2012) 08/28/2012 NY GEDC Guardian App (2012) 08/06/2012 NY GEDC Guardian PPO-DMO App (2012) 08/28/2012 NY GEDC HealthPlex App (2012) 08/06/2012 NY GEDC Humana App (2012) 08/28/2012 NY GEDC IDOA App (2012) 08/06/2012 NY GEDC JJ Stansis App (2012) 08/06/2012 NY GEDC LHI App (2012) 08/06/2012 NY GEDC Master App (2012) 08/02/2012 NY GEDC MetLife App (2012) 08/06/2012 NY GEDC Oxford App (2012) 08/28/2012 NY GEDC Principal App (2012) 08/06/2012 NY GEDC SIDS App (2012) 08/28/2012 NY GEDC Signature App (2012) 08/06/2012 NY GEDC UCCI App (2012) 08/06/2012 NY GEDC UHC App (2012) 08/06/2012 NY GEDC Uni-Care App (2012) 08/06/2012 ODS (GP & Specialty) 2015 03/16/2015 ODS - (General/Specialist) 2009 11/17/2009 Ohio - CAQH App 04/09/2012 OHIO - CLEVELAND CONTRACTS 1 OF 5 11/18/2013 OHIO - CLEVELAND CONTRACTS 2 OF 5 11/18/2013 OHIO - CLEVELAND CONTRACTS 3 OF 5 11/19/2013 OHIO - CLEVELAND CONTRACTS 4 OF 5 11/20/2013 OHIO - CLEVELAND CONTRACTS 5 OF 5 11/20/2013 Ohio Dentaquest Application CAQH 06/04/2013 OK State Form 10.2024 10/23/2024 Ok State Form 2013 08/14/2018 One Call Care - STDA 03/05/2019 One Call Care of TX - STDA 10/2013 10/28/2013 One Call Facility Application 03/24/2013 OR Practitioner Credentialing App 04.26.2017 01/21/2020 OR State Practitioner Credentialing App 2024 07/30/2024 OR State RE-Credentialing App 2024 07/25/2024 ORAQUEST (Dental Associate) 10/07/2009 ORAQUEST (General/Specialist) Oraquest (General/Specialist) So. TX 08/03/2011 ORAQUEST - Texas (Orthodontist) Associate ORAQUEST - Texas (Periodontist) Associate OREGON DENTAL SERVICE (Delta Dental) PPO/Premier 10/22/2009 OSI Humana Medservant Application 09/07/2017 OSI - BLUE CROSS BLUE SHIELD - FL (FL Combined Life) Orthodontist App / Agreement 11-2010 11/22/2017 OSI Access Dental Network (Discount Plan) 2013 01/08/2018 OSI ADI - (DentaQuest App) 2011 05/03/2011 OSI Aetna New Dentist Application 09/11/2017 OSI Aetna PPO/DHMO Add/Full App 2017 01/15/2018 OSI Ameriplan Complete App 2013 01/08/2018 OSI Ameritas Change Form CA 2012 12/04/2017 OSI Ameritas PPO 2014 01/08/2018 OSI Anthem BC PPO App only 2012 12/20/2017 OSI ARGUS DENTAL PLAN - FL (Application) Rev 08/2010 11/22/2017 OSI Assurant DMO CA SPEC 01/08/2018 OSI Assurant HMO TX application and SP agreement 11/28/2017 OSI BCBS - FL (Combined Life) rev 03/03/2011 03/17/2011 OSI BLU CROSS BLUE SHIELD - FL (FCL) Re-Credential / Add Location / Plans 11/2010 11/22/2017 OSI CAQH V.5.0 (2012) 12/20/2017 OSI CAQH V.5.0 Additional Practice Location (2012) 12/20/2017 OSI Careington App & Attestation 2012 12/04/2017 OSI Careington app only 2014 01/08/2018 OSI CAREINGTON APPLICATION - 2010 11/22/2017 OSI Careington Provider App 1/2017 01/15/2018 OSI CONNECTION DENTAL - (App & Individual Agreement) 11/24/2017 OSI Connection Dental Provider App and Agreement CA 2012 12/04/2017 OSI Connection Dental/GEHA App & Agr 1/2017 01/15/2018 OSI DBP/UHC PPO DC Application and Agreement 12/04/2017 OSI DeCare Agreement Dentist Contract 2012 05/17/2017 OSI DeCare App only, updated DDN March 2016 05/23/2017 OSI DeCare Assoc Application 2012 12/04/2017 OSI DECARE DENTAL - CA (app and agreement) 2013 11/24/2017 OSI DECARE DENTAL - MD (add MD Uniform Cred App) 11/24/2017 OSI DECARE DENTAL- All States/ except CA (App & Agreement) 2013 11/24/2017 OSI Delta Care App 2012 12/20/2017 OSI DELTA DENTAL - AZ (PPO Application / Contract) 2010 11/22/2017 OSI DELTA DENTAL - MD (Premier & PPO Agreement) rev 02-03-2010 11/22/2017 OSI Delta Dental CA Add Location 2012 12/04/2017 OSI Delta Dental FL 2012 12/04/2017 OSI Delta Dental LA PPO & Premier Agr 2017 03/13/2017 OSI Delta Dental MD PPO & Premier Agr 2017 03/16/2017 OSI Delta Dental Premier WA Application 07/22/2011 OSI Delta Dental TX DPO & Premier 8/2017 08/28/2017 OSI Delta Dental VA Complete App & Agr 2017 04/02/2017 OSI Delta Dental WA Premier Add location App (Existing Providers) 07/22/2011 OSI DeltaCare Applicatioin 09/07/2017 OSI DENTAL BENEFIT PROVIDERS / UHC - (Agreement & Add Office Form) 2011 11/28/2017 OSI DENTAL PREMIER & PPO - MD (Add MD Uniform Cred App) 11/24/2017 OSI DentaQuest TX Medicaid 12/04/2017 OSI DentaQuest VA application 2017 04/07/2017 OSI DentaQuest VA SFC Agr 2017 04/07/2017 OSI DENTEMAX - (Re-credentialing App) 11/24/2017 OSI Dentemax App & Attestation 2012 12/04/2017 OSI Dentemax MD - add MD Uniform app 11-2011 12/04/2017 OSI DenteMax Provider App CA 2012 12/05/2017 OSI DHA (all states except NC 2013) 01/08/2018 OSI DHA participation agreement only w NCS all states exc IL MA NJ NC 12/04/2017 OSI DHA PPO - (Standard App / Agreement with Ammendment) rev 2011 11/28/2017 OSI Dina Dental 2014 01/08/2018 OSI DNOA - (App & Agreement) 2011 11/24/2017 OSI First Dental Health Add location Form CA 2012 12/05/2017 OSI First Dental Health App and Agr CA 2013 01/08/2018 OSI First Dental Health Provider App and Agreement CA 2012 12/05/2017 OSI Guardian (complete App) 2012 12/20/2017 OSI GUARDIAN PPO - MD (Participation Agreement / Add MD Uniform App) 02/14/2011 OSI Guardian TX Application 09/09/2017 OSI Humana Dentist Application CA 2012 12/05/2017 OSI Humana Location Addendum CA 2012 12/05/2017 OSI Humana Medservant Agreement 09/07/2017 OSI Humana PPO (all states) 2013 01/08/2018 OSI Humana PPO (all states) 2014 01/08/2018 OSI LA Dental Plan 2014 01/15/2018 OSI LA Stand Cred App 2012 12/20/2017 OSI Liberty Dental Facility App CA 2012 12/05/2017 OSI Liberty Dental Ortho Provider App and Agreement CA 2012 12/05/2017 OSI Liberty Dental Pedo Provider App and Agreement CA 2012 12/05/2017 OSI Liberty Provider App 9/2016 01/15/2018 OSI MD Uniform Cred App 2012 12/20/2017 OSI MetLife DHMO (Safeguard) Facility App CA 2012 12/12/2017 OSI MetLife DHMO (Safeguard) Provider App and Agreement CA 2012 12/12/2017 OSI MetLife NC Specific Agreement and Credentialing 02/14/2013 OSI NC State-Mandated Provider Application (2012) 12/20/2017 OSI Premier Access Associate Doctor App CA 2012 12/12/2017 OSI Premier Access Facility App CA 2012 12/12/2017 OSI Premier Access Owner Doctor App CA 2012 12/12/2017 OSI PRINCIPAL - (STD Agreement Only / No App) rev 06/2010 11/22/2017 OSI PRINCIPAL - MD (Application & Agreement) 11/24/2017 OSI Principal Application 09/07/2017 OSI Principal Provider App 7/2016 01/15/2018 OSI Principal Provider App and Agreement CA 2012 12/12/2017 OSI Principal Provider App and Agreement CA 2013 12/20/2017 OSI Principal TX agreement only 11/28/2017 OSI REGENCE BCBS - WA 11/28/2017 OSI Safeguard App & Contract 2011 11/28/2017 OSI Safeguard Complete app 2013 12/20/2017 OSI Safeguard HMO TX application and agreement (add signed FS) 11/28/2017 OSI Safeguard-MetLife HMO FL packet - add fee schedule 08/2011 11/28/2017 OSI SCION DENTAL - (Credentialing Form) 02-07-2011 11/22/2017 OSI SIGNATURE DENTAL PLAN APPLICATION - 2010 12/07/2010 OSI UCCI CA App & Agr 2012 12/20/2017 OSI UCCI DHMO COMPLETE App & Agr- CA 3/2017 01/15/2018 OSI UCCI PPO App & Agr- CA 3/2017 01/15/2018 OSI UHC App 2017 03/24/2017 OSI UHC Provider App CA 2012 12/20/2017 OSI UNICARE - (App & Agreement) 2010 11/24/2017 OSI UNITED CONCORDIA - MA (App & Agreement) 2010 11/22/2017 OSI UNITED CONCORDIA PPO - TX / rev 4-4-2011 11/24/2017 OSI United Health Care Application 09/09/2017 OSI Walden app/agrmt (General Dentist) TX State 05/09/2017 PACIFIC DENTAL BENEFITS (Specialist) PACIFIC UNION DENTAL (General) 10/05/2009 PACIFIC UNION DENTAL (Specialist) 10/05/2009 PACIFIC UNION DENTAL - California (General) 05/14/1902 PACIFICARE DHMO (Signature Value Agreement) 10/07/2009 PACIFICARE DHMO - Arizona 05/31/1902 PACIFICARE DHMO - Arizona (Associate) 09/09/1902 PACIFICARE DHMO - Arizona (Owner) 07/10/1902 PACIFICARE DHMO - Arizona (Specialist) 07/14/1902 PACIFICARE PPO (General/Specialist) 10/07/2009 PARAGON PPO - Florida (General) PARAGON PPO - Florida (Specialist) PATRIOT PLAN - NJ (Specialist) 03/24/2011 PENDANT HEALTH - Texas 05/15/1902 PHEONIX HEALTH PLAN - AZ 06/29/2011 PINNACOL - CO (Specialist App) 03/29/2010 PMI DELTA HMO (Associate) 10/05/2009 PMI DENTAL HMO - California (Orthodontist) 06/11/1902 PMI DENTAL HMO - Southern California (Specialist) 06/11/1902 PREFERRED DENTAL NETWORK - Nevada 04/17/1902 PREFERRED DENTAL NETWORK - Nevada (General/Specialist) 05/16/1902 PREMERA BLUE CROSS - Washington (General/Specialist) PREMERA BLUE CROSS - Washington (General/Specialist) 2009 08/23/2018 PREMERA BLUE CROSS / BLUE SHIELD - Alaska (General/Specialist) PREMIER ACCESS - California (General) 05/24/1902 PREMIER ACCESS - California (Specialist) 05/26/1902 Premier Access - GP/SP/Fac 2012 06/21/2012 PREMIER ACCESS - Healthy Families (Pedodontist) 06/19/1902 PREMIER ACCESS - Nevada 03/29/1902 PREMIER ACCESS - Utah 2010 06/29/2010 Premier Access all states 7/2023 07/22/2023 PREMIER ACCESS DENTAL (Associate Agreement) * 12/13/2019 PREMIER ACCESS DENTAL (Specialist) 10/05/2009 Premier Access PPO (GP & Specialty) AZ NV 3.2014 03/19/2014 PREMIER ACCESS PPO - Arizona (Owner Agreement) 10/05/2009 PREMIER ACCESS PPO - California 01/26/1902 Premier Access. Access all states 9/2023 09/28/2023 PREMIER DENTAL GROUP 10/22/1902 Principal (Texas) 06/03/2015 Principal - Oklahoma 12/30/2011 Principal change form-2015 11/05/2015 PRINCIPAL LIFE DENTAL PLAN PPO (General/Specialist) Standard Agreement 11/19/2010 PRINCIPAL LIFE DENTAL PLAN PPO -Texas (General/Specialist) Principal PPO (GP & SP) OK 11.2011 12/09/2011 PRINCIPAL PPO - CA (General / Specialist) 06/14/2011 Principal PPO - Combined app (General/Specialist) 2011 11/23/2011 Principal PPO Kansas (GP & Specialty) 2012 10/14/2012 PROTECTIVE DENTAL - Oregon (General) PROTECTIVE DENTAL - Washington (General) PROTECTIVE DENTAL CARE (General) Denticare PROTECTIVE DENTAL CARE (Specialist) PROVIDER DENTAL PLANS PPO * QCD GP 2016 03/23/2016 QCD OF AMERICA (General Agreement) * 04/14/2010 QCD OF AMERICA (Specialty Agreement) * 04/14/2010 QCD Specialty 2016 03/23/2016 REGENCE - OR 11/30/2011 REGENCE - Washington 10/05/2009 REGENCE - Washington - 2011 02/02/2012 REGENCE BCBS - OR / WA (Cover Page) 2011 02/18/2011 REGENCE BCBS - WA (GP & SP) 02 / 2011 03/29/2011 REGENCE BLUE CROSS / BLUE SHIELD - Oregon (General/Specialist) REGENCE BLUE SHIELD - Washington 06/12/1902 REGENCE BLUE SHIELD - Washington (Add Associate) 04/11/1902 Renaissance - TN 09/01/2011 RENAISSANCE DENTAL - TN 03/16/2010 Safeguard (Facility) 2011 09/02/2011 SAFEGUARD - (Re-Credentialing) 05/17/1902 SAFEGUARD - DFW (General) 08/20/2010 SAFEGUARD - DFW (Specialist) 10/06/2009 SAFEGUARD - FL (General) 01/11/2013 SAFEGUARD - FL (Specialist) 01/24/2013 SAFEGUARD - N. California (Ortho) 01/21/1902 SAFEGUARD - N. California (Specialist) 01/20/1902 Safeguard - Texas - Recredentialing Application 09/19/2012 SAFEGUARD - TX 04/23/2010 SAFEGUARD / METLIFE HMO - FL (Specialist App / Contract) rev 2009 02/23/2012 SafeGuard Dental Facility Change - Florida 08/08/2012 SAFEGUARD DENTAL HMO & PPO - Florida (General/Specialist) 02/23/2012 SAFEGUARD DENTAL PLAN - Florida (General/Specialist) SAFEGUARD DENTAL PPO/HMO - (General) Attach Fees 10/05/2009 SAFEGUARD DENTAL PPO/HMO - (Specialist) Attach Fees 10/05/2009 SAFEGUARD DFW - (General) 02/17/2012 SAFEGUARD DFW - (Specialist) 03/13/2012 Safeguard DHMO PPO - So. Texas (General) 2011 07/22/2011 Safeguard DHMO PPO - So. Texas (General) 2011 07/22/2011 Safeguard DHMO PPO - So. Texas (Specialist) 2011 07/22/2011 SAFEGUARD DHMO (General Associate) 04/2009 10/05/2009 SAFEGUARD DHMO (Specialty Attached Fees) 04/2009 10/05/2009 SAFEGUARD DHMO - CA (General Dentist) 05/02/2011 Safeguard DHMO - CA (General Dentist) 6.2016 08/25/2016 SAFEGUARD DHMO - CA (General) 06/17/2011 SAFEGUARD DHMO - CA (Ortho / Specialist) 05/06/2011 SAFEGUARD DHMO - CA (Ortho / Specialist) 06/17/2011 Safeguard DHMO - CA (Ortho-Specialist) 6.2016 08/25/2016 SAFEGUARD DHMO - NCA (Specialist) 2009 10/20/2009 SAFEGUARD DHMO / PPO - So. Texas (General) 10/13/2009 SAFEGUARD DHMO / PPO - So. Texas (Specialist) 10/13/2009 SAFEGUARD DHMO/PPO (General/Specialist) - Southern Texas 10/05/2009 SAFEGUARD GENERAL DENTIST - CA 03/23/2010 Safeguard General Dentist CA only 04/24/2025 Safeguard HMO (General Dentist) 6.2023 05/19/2023 Safeguard HMO (GP-TX) 2012 06/11/2012 Safeguard HMO (Ortho-Specialist) 12.2024 12/05/2024 SAFEGUARD HMO (Specialist w/o contract agreement) Safeguard HMO CA (GP) 12.2024 12/12/2024 SAFEGUARD HMO/PPO - Florida (Specialist) Revised 04/09 02/18/2010 SAFEGUARD PPO & HMO - California (General) 03/18/1902 SAFEGUARD PPO & HMO - California (Orthodontist) 10/02/1901 SAFEGUARD PPO & HMO - West Texas (General) 02/06/1903 SAFEGUARD PPO & HMO - West Texas (Ortho) 02/07/1903 SAFEGUARD PPO (Revised 2009) 10/05/2009 SAFEGUARD PPO - Arizona (General/Specialist) SAFEGUARD PPO - Arizona (Specialist) Revised 2008 02/12/1903 SAFEGUARD PPO - Texas (General/Specialist) PPO Office Info with TX PPO contract SAFEGUARD PPO � Arizona (General) 01/08/1903 SafeGuard Recredentialing Application 01/31/2015 Safeguard Southern California General 08/01/09 10/05/2009 Safeguard Southern California Specialist 08/01/09 10/05/2009 SAFEGUARD SPECIALTY - CA 03/23/2010 SAN BERNARDINO MEDICAL GROUP (Reappointment) 10/05/2009 SAVE ON DENTAL PLAN (General/Specialist) 10/07/2009 SAVE ON DENTAL PLAN - Arizona (General & Specialist) 10/08/2009 SAVON DENTAL - NCA 2009 10/22/2009 SAVON DENTAL - Oregon (General) 07/10/1902 SAVON DENTAL - Oregon (Specialist) 07/11/1902 SAVON GENERAL - (Facility Application) 04/22/2010 SAVON SPECIALIST - (Facility Application) 04/22/2010 Scion Application-GA Medicaid - (Georgia) 11/30/2012 SECURE CARE - Arizona (Revised 2009) 10/09/2009 SECURE CARE DENTAL - NV (SPDO) New Office 01/19/2011 SECURE CARE DENTAL - NV (SPDO) New Provider 01/19/2011 SECURITY HEALTH PLAN - WI 11/09/2010 SELECT HEALTH - (Provider App) 04/21/2011 SELF INSURED DENTAL SERVICES 10/07/2009 Signature Dental Plan (GP & SP) 08/29/2017 SIGNATURE PREFERRED PROVIDER NETWORK (GE Wellness) SMILEBRAND (General) signature - UTAH Part I 04/10/2012 SMILEBRAND (General) signature - UTAH Part II 04/10/2012 SMILESAVER HMO / SIGNATURE DENTAL PLAN (w/o fee schedules) SMILESAVER HMO / SIGNATURE DENTAL PLAN - California (General) Associate Agreement SMILESAVER HMO / SIGNATURE DENTAL PLAN - California (Specialty) 10/07/2009 So Cal Test 2 08/02/2011 SOLSTICE 11/19/2010 Solstice (GP & SP) 2021 06/23/2021 SOLSTICE - FL (Application & Agreement) 07/22/2011 Solstice Application - (Georgia) 07/13/2013 SOLTICE BENEFITS - Cred App w/ 25% Addendum 05/25/1902 SOONER CARE 06/06/2011 SOUTHWEST ADMINISTRATORS (Joint Council of Teamsters No. 42 Agreement) SOUTHWEST ADMINISTRATORS - (Facility Application) 04/22/2010 Southwest Preferred Dental AZ & NV 2016 03/24/2016 SOUTHWEST PREFERRED DENTAL ORGANIZATION - Arizona (General) 10/05/2009 SPDO - Arizona 2009 10/05/2009 SPDO SW Preferred Dental (GP & SP) 11.2023 12/06/2023 STAR HEALTH - So. TX (Foster Care) 11/23/2010 State Mandated Form - Maryland 10/18/2011 STDA - Maverest - TX 08/19/2013 Superior Dental - OH 09/20/2012 TAKECARE - HI 07/13/2010 TakeCare HI 05052023 06/09/2023 TakeCare HI 2014 11/06/2014 TDA (GP & SP) AZ 08.2017 03/15/2018 TDA (GP) 2015 03/13/2015 TDA (Ortho) 2015 03/13/2015 TDA (Pedo) 2015 03/13/2015 TDA (Pros) 2015 03/13/2015 TDA (Specialty OS, EN & Perio) 2015 03/13/2015 TDA (Well Health) NV 08.2017 09/28/2017 Teachers Health Trust NV 2011 08/20/2011 TEAMSTERS 12/22/1901 Texas Medicaid 09/12/2011 TEXAS MEDICAID HEALTHCARE PARTNERSHIP (TMHP) 09/22/2012 TEXAS STANDARDIZED APPLICATION 03/27/2013 TOTAL DENTAL ADMINISTRATORS - (Ortho) 01/15/1903 TOTAL DENTAL ADMINISTRATORS - Utah (General/Specialist) 07/22/1902 Total Dental Administrators 2016 01/24/2016 Total Dental Administrators DHMO/PPO-AZ SP PEDO (09/2009) 10/05/2009 TOTAL DENTAL ADMINISTRATORS PPO - Arizona (General) 11/08/2011 TOTAL DENTAL ADMINISTRATORS PPO - Colorado (General) TOTAL DENTAL ADMINISTRATORS PPO HMO - Arizona (General) 06/09/1902 Tricare~South Region 11.2012 11/23/2012 TSCA - STDA 04/05/2019 TX CHIP - STDA 09/19/2012 TX Standard Cred App - STDA 05/31/2017 02/09/2018 UCCF 02/21/2016 UCCI 2015 12/11/2015 UCCI (GP & Specialty) AZ 2013 04/28/2013 UCCI (GP & Specialty) AZ, KS 3.2014 03/19/2014 UCCI (GP & Specialty) KS 2013 04/28/2013 UCCI (GP & Specialty) NV 06/21/2012 UCCI (GP & Specialty) NV 2013 04/28/2013 UCCI (GP & Specialty) NV 3.2014 03/19/2014 UCCI (GP & Specialty) OR, OK 3.2014 03/19/2014 UCCI (GP & Specialty) OR, OK, HI 2012 06/21/2012 UCCI (GP & Specialty) WA 3.2014 03/19/2014 UCCI - (Facility Application) 04/22/2010 UCCI - AZ (NA) GP & SP 1.2018 01/18/2018 UCCI - AZ, NA 4.2.2018 04/05/2018 UCCI - HI, NA 4.2.2018 04/05/2018 UCCI - STDA 04/04/2018 UCCI - WA, NA. PNA. 4.2.2018 04/11/2018 UCCI AZ & KS NA 09.2018 09/27/2018 UCCI AZ NA 09.2018 09/27/2018 UCCI AZ, NV, OK, KS, WA, OR, HI 2.2018 02/28/2018 UCCI HMO / PDS - (Owner) 03/25/2010 UCCI OR & OK PNA 09.2018 09/27/2018 UCCI OR 7/11/2018 09/10/2018 UCCI OR PNA 09.2018 09/27/2018 UCCI PPO - Arizona (General/Specialist) 10/22/2009 UCCI PPO - OR (General / Specialist) 07/2010 06/25/2010 UCCI PPO - STDA 09/19/2013 05/02/2014 UCCI PPO - WA (General/Specialist) 2012 06/21/2012 UCCI PPO/ DMO (General/Specialist) - NJ 08/12/2011 UCCI PPO/ DMO (General/Specialist) - PA 08/12/2011 UCCI WA PNA & NA 09.2018 09/27/2018 UHC Texas 2015 12/11/2015 UHC - VA & MD 10/31/2012 UHC APP-FL 11/30/2012 UHC Recred - STDA 02/19/2017 UHC-DBP Existing Provider location Form 10/05/2009 UNI CARE - (Traditional PPO) Contract With Other States 03/04/1903 UNI CARE - Oregon (General / Dental Blue) 03/02/1903 UNI CARE - Oregon (Specialist / Dental Blue) 03/04/1903 UNI CARE - Washington (General / Dental Blue) 03/03/1903 UNI CARE - Washington (Specialist / Dental Blue) 03/03/1903 UNI CARE / WELLPOINT - OR / WA (General) 2009 01/11/2010 UNI CARE / WELLPOINT - OR/ WA (Specialist) 2009 01/11/2010 UNI-CARE - Southern California (GP & SP) 2010 01/11/2010 Uni-Care Application - (Georgia) 08/05/2013 Uni-Care Dental 03.2019 04/01/2019 UNI-CARE DISCOUNT DENTAL PLAN - Arizona (General/Specialist) 03/09/1903 UNI-CARE DISCOUNT PLAN - California 10/05/2009 UNI-CARE DISCOUNT PLAN - OR/WA (General/Specialist) 2009 10/22/2009 UNI-CARE INC - NCA (General/Specialist) 2009 10/20/2009 UNICARE - (Office Profile) 11/02/1902 Unicare - STDA 03/04/2019 UNICARE - Texas (General/Specialist) 12/31/1902 UNICARE -STDA 01/24/2014 UNICARE / WELLPOINT - New Jersey (Specialist) 02/17/2011 Unicare AZ, OK, KS, HI, OR (GP & SP) 2016 03/25/2016 UNICARE DENTAL AGREEMENT 10/12/2009 UNICARE DISCOUNT - FL 11/09/2010 UNICARE INC - Southern California (GP & SP) Dental Agreement 10/08/2009 UNICARE INC. - (General/Specialist) 10/15/2009 UNICARE PPO - STDA 01/09/2013 Unicare. Anthem. Wellpoint - AZ, OR, WA, HI 2.2018 04/06/2018 United Concordia (GP & SP) AZ, 1.2018 02/28/2018 United Concordia (GP & SP) AZ, KS, OR, OK, 3.2017 03/13/2017 United Concordia (GP & SP) HI 3.2017 03/13/2017 United Concordia (GP & SP) NV 3.2017 03/13/2017 United Concordia (GP & SP) WA 3.2017 03/13/2017 United Concordia (GP & Specialty) KS AZ (Parnet-NFFS) 10/13/2015 United Concordia (GP & Specialty) OR, OK 10.2016 02/11/2017 United Concordia (GP & Specialty) WA 10.2016 02/11/2017 UNITED CONCORDIA (NFFS) - Ohio 05/02/1902 UNITED CONCORDIA (UCCI) PPO - Texas 06/13/1902 UNITED CONCORDIA - (Facilty App) 05/25/2010 UNITED CONCORDIA - (Recredential) 11/19/2010 United Concordia - AZ, KS (NA/NFFS) 12.2020 12/23/2020 UNITED CONCORDIA - CA (General) 04/19/2011 United Concordia - CA (General) DHMO/NFFS 12.2020 01/21/2021 United Concordia - CA (General) DHMO/NFFS/PARNET 03.2017 03/06/2017 United Concordia - CA (Specialty) DHMO/NFFS 12.2020 01/21/2021 United Concordia - CA (Specialty) DHMO/NFFS/PARNET 03.2017 03/06/2017 United Concordia - DHMO/NFFS (General) 10.2016 12/03/2016 United Concordia - DHMO/NFFS - NCA (General) 11/21/2014 United Concordia - DHMO/NFFS - NCA (Specialist) 11/21/2014 United Concordia - DHMO/NFFS/PARNET (General) 10.2016 12/03/2016 United Concordia - DHMO/NFFS/PARNET - SCA (General) 11/21/2014 United Concordia - DHMO/NFFS/PARNET - SCA (Specialist) 11/21/2014 UNITED CONCORDIA - FL 01/27/2012 United Concordia - HI (NA/NFFS) 12.2020 12/23/2020 UNITED CONCORDIA - NCA (GP) 2010 06/25/2010 United Concordia - NV (NA-NFFS) 9.2023 10/04/2023 United Concordia - OK (PNA/NFFS) 12.2020 12/23/2020 UNITED CONCORDIA - OR (General/Specialty) 2009 11/19/2009 United Concordia - OR (PNA/NFFS) 12.2020 12/23/2020 UNITED CONCORDIA - Texas (General) 06/07/2013 UNITED CONCORDIA - Texas (Owner) 06/07/1902 UNITED CONCORDIA - Texas (Specialist) 01/25/2012 United Concordia - Texas - Recredentialing Application 09/19/2012 UNITED CONCORDIA - WA (General/Specialty) 2009 11/19/2009 United Concordia - WA (PNA/NFFS) 12.2020 12/23/2020 UNITED CONCORDIA - Washington 10/05/2009 UNITED CONCORDIA ADVANTAGE- California (General/Specialist) Rev 4/2009 09/21/2011 United Concordia Application - (Georgia) 08/31/2012 United Concordia AZ (GP & SP) 10.2016 10/27/2016 United Concordia AZ (GP & SP) 2016 01/24/2016 United Concordia AZ, KS, OK (GP & SP) 5.2016 05/06/2016 UNITED CONCORDIA DHMO APPLICATION ONLY(General) Rev 4/2009 10/05/2009 UNITED CONCORDIA DHMO/NFFS/Advantage Plus - California (General) 09/21/2011 United Concordia HI (GP & SP) 5.2016 05/06/2016 UNITED CONCORDIA NATIONAL FEE FOR SERVICE- Calfornia (General/Specialist) 4/2009 10/05/2009 United Concordia NV (GP & SP) 10.2016 12/04/2016 United Concordia OR (GP & SP) 5.2016 05/06/2016 United Concordia OR, OK (GP & SP) 10.2016 10/27/2016 United Concordia PPO & DHMO Specialty Application (Southern California) 01-01-09 10/05/2009 UNITED CONCORDIA PPO & HMO - Arizona (General/Specialist) 06/21/2012 UNITED CONCORDIA PPO & PARNET - Oklahoma 03/13/2012 UNITED CONCORDIA PPO & PARTNET - Arkansas 12/14/2011 UNITED CONCORDIA PPO (FFS & Partnet) - Georgia 07/07/1902 UNITED CONCORDIA PPO (FFS & Partnet) - New Jersey 05/05/1903 UNITED CONCORDIA PPO (PNA Agreement) 2009 10/05/2009 UNITED CONCORDIA PPO - Arizona (General/Specialist) Revised 2008 10/16/1902 UNITED CONCORDIA PPO - California 10/07/2009 UNITED CONCORDIA PPO - Colorado 10/08/2009 UNITED CONCORDIA PPO - Oregon (FFS) 02/09/1902 UNITED CONCORDIA PPO - Washington (FFS) 10/05/2009 UNITED CONCORDIA PPO/DMO - TN 03/16/2010 United Concordia WA (GP & SP) 10.2016 10/27/2016 United Concordia WA (GP & SP) 5.2016 05/06/2016 United Corcordia - CA (General) 09.2013 01/24/2014 UNITED DENTAL CARE - (Family Dentist Agreement) 10/07/2009 UNITED DENTAL CARE - (Ortho) 10/07/2009 UNITED DENTAL CARE - (Specialty Provider Agreement / No App) 05/30/1902 UNITED DENTAL CARE / FORTIS LEGEND SERIES & HERITAGE - Texas (General/Specialist) United Dental Care HMO - CA - General 2018 03/02/2018 United Dental Care HMO - CA - Specialty & Ortho 2018 01/16/2018 United Dental Care HMO All States 08.20.2024 08/23/2024 United Dental Care HMO Existing Provider Form 10/05/2009 UNITED DENTAL HEALTH CARE - California (General) 12/11/2009 UNITED HEALTHCARE - California (General) 10/05/2009 UNITED HEALTHCARE - California (Specialist) 10/05/2009 UNITED HEALTHCARE - Colorado (Associate) UNITED HEALTHCARE - So. Texas (General/Specialist) 10/15/2009 United Healthcare Application - (Georgia) 02/03/2012 UNIVERSAL CARE - (Dental Application) 03/23/1903 UNIVERSAL CARE HMO (General) - Owner USACARE - Colorado (General) * VA SFC DentaQuest App 6/2012 08/09/2012 VA-Ameritas 10/14/2012 VA-Delta Dental PPO & Premier 09/17/2012 VA-Dominion Dental 09/17/2012 VA-Maverest Dental Network 09/17/2012 VA-United Concordia PPO 09/17/2012 VA-Wellpoint/Unicare/Anthem 10/10/2012 VERIFPOINT (Credentialing Form) 07/07/2010 VERIFPOINT PROV FORM - 2011 11/25/2014 WASHINGTON / COMPLETE ADD LOCATION PKT - (General) 08.2010 BND 10/13/2010 WASHINGTON / COMPLETE ADD LOCATION PKT - (Specialty) 08.2010 BND 11/12/2010 WASHINGTON COMPLETE ADD LOCATION PKT - (GP & SP) 03.11 BN!D 04/19/2011 WASHINGTON DENTAL SERVICE - (All Specialty Except Ortho) 04/09/1902 WASHINGTON DENTAL SERVICE - (General) 04/10/1902 WASHINGTON DENTAL SERVICE - (General) 02/2010 02/12/2010 WASHINGTON DENTAL SERVICE - (Ortho) 04/10/1902 WASHINGTON DENTAL SERVICE - WA (General) 03/2011 03/28/2011 WASHINGTON DENTAL SERVICE - WA (Specialty) 04/2010 04/23/2010 WASHINGTON DENTAL SERVICE - WA (Specialty) Add Location 04/2010 04/23/2010 Washington Dental Service WA(Specialist) 2009 10/05/2009 Washington Dental Service WA-(General) 2009 10/05/2009 WASHINGTON DENTAL SERVICES - (General) 11/2009 11/18/2009 WASHINGTON DENTAL SERVICES ADD LOCATION - (General) 03/2010 03/17/2010 WASHINGTON STATE DENTAL LICENSE APPLICATION 12/23/1902 Washington State Practitioner Addtl Loc app (GP & SP) 2.16 03/02/2016 Washington State Practitioner Application (GP & SP) 11.2013 12/11/2013 Washington State Practitioner Application (GP & SP) 2.2016 03/01/2016 Washington State Practitioner Application - January 2023 11/14/2023 WDS - WA (General Add Location) 07/2010 07/21/2010 WDS - WA (General) 07/2010 07/21/2010 WDS - WA (General) 10/2010 10/08/2010 WDS - WA (Specialty Add Location) 07/2010 07/21/2010 WDS - WA (Specialty) 07/2010 07/21/2010 WDS - WA (Specialty) 10/2010 10/08/2010 WEA PROVIDER UPDATE - WI 11/09/2010 WELLMARK BCBS - Iowa 11/09/2010 WELLMARK BLUE CROSS / BLUE SHIELD - South Dakota Wellpoint (General) - MD 08/10/2011 Wellpoint (General) - PA 01/03/2013 Wellpoint (Specialist) - MD 08/09/2011 Wellpoint (Specialist) - PA 08/09/2011 WELLPOINT - (General Dentist Agreement) 11/19/2010 WELLPOINT - (Spec Dentist Agreement) 11/19/2010 Wellpoint - OH & Indiana 09/20/2012 WELLPOINT - Oklahoma (Owner) 05/05/2011 WELLPOINT - Texas (General) 12/10/2009 WELLPOINT - Texas (Specialist) 12/10/2009 WELLPOINT - TN (General) 12/18/2009 WELLPOINT / UNICARE - AZ,OR,HI (General) 2010 08/20/2010 WELLPOINT / UNICARE - Oklahoma 08/06/2010 WELLPOINT / UNICARE PPO ONLY - AZ, OR, HI (Specialist) 2010 08/20/2010 WELLPOINT ANTHEM BCBS PB - NCA (GP) 04/19/2011 WELLPOINT ANTHEM BCBS PB - NCA (SP) 04/19/2011 WELLPOINT APP-FL 01/27/2012 WELLPOINT CREDENTIAL APP - OR / WA / NCA (GP/SP) 03/12/2010 WELLPOINT DENTAL PPO - Al States Except California (General) 10/08/2009 WELLPOINT GROUP - OR / WA (General) 2010 06/24/2010 WELLPOINT GROUP - OR / WA (Specialty) 2010 06/24/2010 WELLPOINT GROUP PPO - (Specialist) Eff. 2008 03/04/1902 WELLPOINT GROUP PPO - NCA (General) 2009 12/14/2009 WELLPOINT GROUP PPO - NCA (Specialist) 2009 12/14/2009 WellPoint HI 2014 11/06/2014 Wellpoint OR & HI Cred App 3.2016 03/23/2016 WELLPOINT PPO 10/07/2009 Wellpoint PPO (General/Specialist) - VA 08/06/2011 WELLPOINT PPO - Massachusetts (General / Specialist) 05/26/1902 Wellpoint PPO - MD 08/10/2011 Wellpoint-Anthem NV (GP & SP) 10.2011 11/06/2011 Wellpoint-Unicare AZ, OK, KS, HI, OR (GP & SP) 10.2011 10/13/2015 Wellpoint. DeCare 9.2024 AZ, HI, KS, OK, OR 09/17/2024 Wellpoint/Unicare (GP & SPC) all States except TX & PA 01/20/2012 Wellpoint/Unicare (Gp & SPC) Texas 12/19/2012 Western Dental - CA (Specialist) 2020 03/06/2020 WESTERN DENTAL - CA 1.2017 06/14/2018 WESTERN DENTAL - Southern California (General) 2009 10/05/2009 WESTERN DENTAL HMO (Oral Surgery & Periodontist) WESTERN DENTAL HMO (Orthodontist) Western Dental HMO 2022 06/21/2022 WESTERN DENTAL PLAN (Coastal Dental) - California * Western Dental Plan Management - Coastal (Endo) 10/25/2012 Western Dental Plan Management - Coastal (General/Pedo) 10/27/2012 Western Dental Plan Management - Coastal (Oral Surgery) 10/25/2012 Western Dental Plan Management - Coastal (Ortho) 10/25/2012 Western Dental Plan Management - Coastal (Perio) 10/25/2012 Zelis (General/Specialist) - CA & AZ 04/12/2017 Zelis NV 4.2017 04/13/2017 Zelis NV 7.2022 10/02/2023
Chiro	- - - - - - - - - - - - - - - - - - - - SELECT AN APPLICATION - - - - - - - - - - - - - - - - - - - AMERICAN ASSOCIATION OF HEALTH PLANS (AAHP) ANTHEM BLUE CROSS - CA (Specialty) 04/15/2011 ANTHEM BLUE CROSS / BLUE SHIELD - Colorado ANTHEM BLUE CROSS / BLUE SHIELD - Nevada ANTHEM BLUE CROSS / BLUE SHIELD - New Hampshire BLUE CROSS / BLUE SHIELD (HMO) - New Mexico BLUE CROSS / BLUE SHIELD - Montana CAL OPTIMA CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) CAPP CARE PPO CAREFIRST BLUE CROSS / BLUE SHIELD (Non-physician Application) CIGNA HEALTHCARE - New Hampshire demo demo 1 04/26/2023 FAMILY HEALTH AMERICA * HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - New Hampshire HARVARD PILGRIM HEALTHCARE OF NEW ENGLAND - Rhode Island KEMPER PREFERRED PROVIDER NETWORK NETWORK MEDICAL MANAGEMENT * 03/22/1903 UHS CHIROPRACTIC (Credentialing) WELLMARK BLUE CROSS / BLUE SHIELD - South Dakota
State	- - - - - - - - - - - - - - - - - - - - SELECT AN APPLICATION - - - - - - - - - - - - - - - - - - - ALABAMA MEDICAID (Out-of-State) ALABAMA MEDICAID (Physician/Dentist/Audiologist) ALABAMA UNIFORM CREDENTIALING APPLICATION 10/22/2009 CALIFORNIA PARTICIPATING PHYSICIAN APPLICATION 07/18/2013 CALIFORNIA PHYSICIAN RECREDENTIALING APPLICATION 07/18/2013 CARE HOSPITAL AUTHORIZATION FORM - Oregon (Specialist) 06/27/1902 COLORADO STANDARDIZED CREDENTIALING APPLICATION 10/22/2009 DENTAL REFERRAL FORM - Oregon (Specialist) 09/21/1902 Florida - (Initial) 04/20/2011 GEORGIA - (Initial / AHP) 04/22/2011 GEORGIA - (Initial) 04/20/2011 GEORGIA - (Recred / AHP) 04/22/2011 GEORGIA - (Recred) 04/22/2011 ILLINOIS DEPT. OF PUBLIC AID (Illinois) Medical Assistance Program * ILLINOIS STANDARDIZED RECREDENTIALING APPLICATION 10/22/2009 ILLINOIS UNIFORM CREDENTIALING APPLICATION 10/07/2009 IOWA STANDARDIZED CREDENTIALING APPLICATION 11/12/2009 IOWA STANDARDIZED RECREDENTIALING APPLICATION 11/12/2009 KANSAS STANDARDIZED CREDENTIALING APPLICATION KENTUCKY STANDARD CREDENTIALING APPLICATION 11/06/2009 KENTUCKY STANDARD RECREDENTIALING APPLICATION 11/06/2009 LOUISIANA STANDARDIZED CREDENTIALING APPLICATION 11/13/2009 MAINE - (Allied) 04/05/2011 MAINE - (Initial) 09/17/2014 MAINE - (Recred) 09/17/2014 MAINE UNIFORM CREDENTIALING APPLICATION 12/03/1902 MARYLAND UNIFORM CREDENTIALING APPLICATION - (Medical) 03/21/1903 MARYLAND UNIFORM CREDENTIALING FORM (Dental) 10/07/2009 MASSACHUSETTS STANDARDIZED CREDENTIALING APPLICATION 10/22/2009 MASSACHUSETTS STANDARDIZED RECREDENTIALING APPLICATION 10/22/2009 MEDI-CAL (Provider Agreement) 10/07/2009 MEDICARE - CMS 855I (Individual) MICHIGAN - (Initial) 04/27/2011 MINNESOTA UNIFORM CREDENTIALING APPLICATION 05/23/2012 MINNESOTA UNIFORM RECREDENTIALING APPLICATION MISSISSIPPI UNIFORM CREDENTIALING APPLICATION MISSOURI UNIFORM CREDENTIALING APPLICATION 10/07/2009 NATIONAL HERITAGE INSURANCE COMPANY - Texas (Dental Medicaid) NEVADA STANDARDIZED RE-CREDENTIALING APPLICATION 11/20/2009 NEW HAMPSHIRE UNIFORM CREDENTIALING APPLICATION NEW JERSEY - (Initial) 04/26/2011 NEW JERSEY - (Recred) 04/26/2011 NEW MEXICO STANDARDIZED CREDENTIALING APPLICATION 10/22/2009 NEW MEXICO STANDARDIZED RECREDENTIALING APPLICATION 10/22/2009 NEW YORK MEDICAID 05/30/1902 NORTH CAROLINA STANDARDIZED CREDENTIALING APPLICATION 11/19/2009 OHIO STANDARDIZED CREDENTIALING APPLICATION OKLAHOMA UNIFORM CREDENTIALING APPLICATION OR Practitioner Credentialing App 04.2017 05/14/2019 OR Practitioner ReCredentialing App 04.2017 04/15/2019 PENNSYLVANIA - (Initial) 05/02/2011 SC UNIFORM MANAGED CARE PROVIDER - (Credentialing Application) 04/11/2011 SOUTH DAKOTA UNIFORM CREDENTIALING APPLICATION TEXAS STANDARDIZED APPLICATION 03/27/2013 TEXAS UNIFORM CREDENTIALING APPLICATION 03/27/2013 WA State Application 12.2017 - recvd 9/2018 09/28/2018 WASHINGTON DEPT. OF LABOR & INDUSTRIES CRIME VICTIMS PROGRAM Washington Dept. of Labor & Industries Non-Network Provider 2013 09/06/2013 WASHINGTON STANDARDIZED CREDENTIALING APPLICATION 03/31/2011 Washington State Practitioner Application (GP & SP) 12/2017 08/09/2018 WEST VIRGINIA STANDARDIZED CREDENTIALING APPLICATION 04/18/2013 WEST VIRGINIA STANDARDIZED RE-CREDENTIALING APPLICATION 04/18/2013
Facility	- - - - - - - - - - - - - - - - - - - - SELECT AN APPLICATION - - - - - - - - - - - - - - - - - - - BCBSMA Urgent Care App 06/05/2013 Cigna- Ancillary Credentialing application 05/28/2013 Coventry Facility Application 06/05/2013 Harvard Pilgrim Ancillary App 05/07/2012 MultiPlan RFI Medical Clinic 10/10/2012 MultiPlan RFI Urgent Care Center 10/08/2012 Tricare North Group 10/08/2012 Tricare North Individual Phys 10/08/2012 Tricare South Group 10/08/2012 Tricare South Individual Phys 10/08/2012 United Healthcare Urgent Care App 06/05/2013