Get MD Uniform Dental Credentialing Form 2008-2022
CODE YES NO LICENSE ISSUING STATE IF THIS IS A STATE LICENSE, ARE YOU CURRENTLY PRACTICING IN THIS STATE? Other ID Numbers Indicate all that apply. ARE YOU A PARTICIPATING MEDICAID PROVIDER?* YES NO Provider Type Code List is found on Page 24. YES NO MEDICAID NUMBER Indicate all that apply. MEDICAID STATE WORKERS COMPENSATION NUMBER USMLE NUMBER (WITHOUT HYPHENS) — ECFMG CERTIFICATE ISSUE DATE (NON-U.S./CANADIAN GRADUATE ONLY) (MM/DD/YYYY) ECFMG NUMBER (NON-U.S./CANADIAN GR.
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