Apply for Dentalink IPA Membership | Join Our Independent Dental Network

Join Membership Dentalink IPA, Apply Now!

Submit the application form below and experience the Dentalink IPA advantage. Our streamlined application process makes it easy to start saving while staying independent.

Membership Application Form

Practice Information

Let's start off with a few simple details about your practice.

Practice Name

Practice Phone Number

Practice Email

Practice Website Address (optional)

Specialty

Gross Production Level

Year Founded

Practitioner Information

Tell us about practitioners in your practice.

Practitioner First Name

Practitioner Last Name

Primary Practitioner Email

Primary Practitioner Phone

Primary Practitioner License Number

Number of Practitioners

Practitioner 2 Name

Practitioner 2 License Number

Practitioner 3 Name

Practitioner 3 License Number

Practitioner 4 Name

Practitioner 4 License Number

Practitioner 5 Name

Practitioner 5 License Number

Practitioner 6 Name

Practitioner 6 License Number

Practitioner 7 Name

Practitioner 7 License Number

Practitioner 8 Name

Practitioner 8 License Number

Practitioner 9 Name

Practitioner 9 License Number

Practitioner 10 Name

Practitioner 10 License Number

Main Point of Contact

This information is used to create your Dentalink IPA membership user account.

Main Point of Contact Name

Main Point of Contact Email

Main Point of Contact Phone

Preferred Method of Contact

Phone

Text Message

Location Information

Please include the details for all of your locations below.

Primary Location Address

Street Address

City

State

Zip Code

Primary Location Phone

Primary Location Tax ID Number (EIN)

How many locations do you have?

Referrals

We'd love to hear more about how you found out about Dentalink IPA

How did you hear about Dentalink IPA?

Who may we thank for the referral? Type Referrer Name