Follow the steps to accurately complete your credentialing application.

1. Click ‘Get Form’ button to obtain the Credentialing Application and open it in your preferred online editor.
2. Begin with the general information section. Fill out personal details such as first name, middle name, last name, individual NPI number, and date of birth. Be sure to include your social security number and select your specialty from the options provided.
3. Proceed to the license and certificates section. Enter your current state license number along with its expiration date. If applicable, include previous state license numbers and their expiration dates, as well as your professional liability insurance details.
4. In the dental education section, provide details regarding your dental school and graduation date. You may also include any specialty training and whether you are board certified, along with relevant dates.
5. Navigate to the work history section to detail your employment history over the past five years. Provide names of practices or employers along with the start and end dates. If there are employment gaps longer than six months, be prepared to explain these.
6. Complete the confidential questions section accurately. Indicate yes or no for each question and be prepared to provide explanations if required.
7. In the authorization and release section, read through the statements carefully. Provide your signature and printed name along with the date to confirm your agreement and consent.
8. After filling in all sections, review the entire application for any missing information or mistakes. Ensure that all requested documents are attached.
9. Finally, save your changes in the online editor, then download, print, or share the finished application as necessary to submit it for processing.

Begin your application process online today and complete your Credentialing Application with confidence!