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Dentist Registration

To register as a dentist, please fill out the form below. We do not ever charge any fee to our participating dentists.

If your office has other dentists who may want to register as participating dentists in NYDN, please ask each dentist to register separately.

Personal & Login Information

First Name
Last Name
Dental Degree
Dental School Granting Degree:
Year Granted
Specialty:
Website Address: (optional)
Your Primary Office Address
Street Address:
Suite or Room Number: (optional)
City or Borough:
Neighborhood: (Local identifier - optional)
State:
Zip:
Phone Number:   Digits only: 123 456 7890
County
Your Secondary Office Address (Optional)
Street Address:
Suite or Room Number:
City:
Neighborhood: (Local identifier - optional)
State:
Zip:
Phone Number:   Digits only: 123 456 7890
County
Your Login Information
Your Email
Email will be used as our primary means of correspondence with you.
Your email address will be kept as confidential, for internal use only.
Re-type Email
Password
(last 4 digits of SS number)
This password protocol uses (last four digits of SS number) for simplicity. This password will be used for editing dental practice information on our website to reflect future changes. It will also be used by each participating dentist who wants to create his/her own page on our website. You are welcome to ask us for assistance in creating this personal page, after your basic registration has been completed and approved by us. NYDN does not charge dentists for any of these services.
Re-type Password (last 4 digits of SS number)
Please Note: We do not ever charge a fee to our participating dentists.

I have read and I accept the dental agreement and am ready to join New York Dental Network, LLC.


Yes

No