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Get ADA J400 2006

45. Treatment Resulting from Occupational illness / injury Auto accident TREATING DENTIST AND TREATMENT LOCATION INFORMATION X Date 54. NPI – © 2006 American Dental Association 56A. Provider Specialty Code 57. Phone Number ( 58. Additional Provider ID 51. SSN or TIN 50. License Number ) 55. License Number 56. Address, City, State, Zip Code ( Other accident 47. Auto Accident State 46. Date of Accident (MM/DD/CCYY) Signed (Treating Dentist) 52. Phone Number Model(s) 41. .

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