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

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

Completed, signed, and dated application, 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:

  • Include any required written explanations.

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.

Additional items that may be requested:

  • Copy of all active dental licenses.
  • 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.

Step 2: Download and fill out the Connection Dental Attestation form.

Step 3: Click this link to download the participating provider agreement.

Step 4: Collect any additional documents needed that are listed in your application.

Step 5: 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 1: Click this link to download the Connection Dental Network Application

Step 2: Click this link to download the participating provider agreement.

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.