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