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Join the network where millions of members are waiting to access your practice.

Your Connection Dental Network Application cannot be processed without the following information:

Completed, signed, and dated application (current version), including:

• Last five years of dental work history, with explanations of any gaps of 180 days or more.
• New graduates with less than five years’ work history must account for gaps of 180 days or greater between licensure date and work history start date.
• Completion dates for all dental training and education.

Completed, signed, and dated attestation within 120 days prior to submission, if applicable:

• Attestations are included in all applications, EXCEPT for the Oklahoma State-Mandated Application—Oklahoma dentists must use the Connection Dental Attestation, which can be downloaded, as indicated in Step 2 below.
• Include any required written explanations.
• Attestations not meeting these requirements cannot be accepted

Completed, signed and dated Participating Provider Agreement:

• 1st page of fee schedule that applicant received from Connection Dental Network. If this is not submitted, a fee schedule will be assigned by Connection Dental Network.
• Copy of current professional malpractice insurance declaration.
• Copy of all active dental, sedation, and anesthesia licenses, if applicable
• Copy of DEA certificate in all states of practice, or waiver if applicable

Additional items that may be requested:

• Copy of diploma if foreign educated or trained

Does your practice reside in any of the states below?

If you are in a state that uses mandated credentialing forms, your state is requiring you to use their form.

Step 1: Download your state's form by clicking the state name below.

State Mandated Applications

Mandated CAQH Applications

Step 2: Download and fill out the Connection Dental Attestation form-Oklahoma applications only click here.

Step 3: Download and fill out the Connection Dental FWA/Attestation form-All other states click here.

Step 5: Collect any additional documents needed that are listed in your application.

Step 6: Visit our Contact page to obtain contact information for your state network representative. You can also fax your completed forms and documents to: (816) 257-4439.

If your state wasn't listed above, please follow the steps below.

Step 3: Collect any additional documents needed that are listed in your application.

Step 4: Visit our Contact page to obtain contact information for your state network representative. You can also fax your completed forms and documents to: (816) 257-4439.

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