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Tist Oral Pathologist Pediatric Dentist Dental Anesthesiologist Board Certified Endodontist Pain Management (Please explain) Date of Certification (MM/YYYY) Periodontist Other (Please explain) Oral & Maxillofacial Surgeon Dual Degree B. Please check procedures you will perform in your practice: Orthodontic Full Mouth Banding Year you began this procedure (YYYY) Sinus Lifts Placement of Mini Implants for Orthodontic/Prosthesis Implant Prosthesis/Supported Prosthesis Palatal Inserts.

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