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CartSusie Oliver2021-12-03T03:50:10-05:00

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Thousands of Dentists,
One Voice

Step 1 of 11

9%

What is your practice specialty?*
- General Dentist
- Endodontist
- Oral Surgeon
- Orthodontist
- Pediatric Dentist
- Periodontist
- Prosthodontist
Where is your practice located?*
What is your practice zip code?*

How many dentists are in your practice?*
- 1
- 2-4
- 5+
How many locations?*
- 1
- 2
- 3
- 4+

When was your practice UCR last increased:*
- within the last 12 months
- within the last 24 months
- more than 24 months ago

What is the estimated Gross Annual Revenue for your practice?*
- $250k to $499K
- $500k to $749K
- $750k to $1.24M
- $1.25M to $2.9M
- $3M-$5M
- $5M +

What percentage of revenue comes from PPO's?*

The practice holds In-Network PPO contracts with: (check all that apply)*
- None of these
- Aetna
- Anthem
- Ameritas
- Assurant
- Blue Cross
- Cigna
- Companion Life
- Delta Dental
- Guardian
- Humana
- Medicare Advantage Plus
- MetLife
- Principal
- United Concordia
- United Healthcare

The practice holds In-Network Umbrella PPO contracts with: (check all that apply)*
- None of these
- Careington
- Connection Dental / GEHA
- Dentemax
- Diversified
- Maverest / Stratose / Zelis
- Premier

What practice management software do you use?*
- Dentrix
- Eaglesoft
- Open Dental
- Other
Do you offer health insurance to your employees?*
- Yes
- No

Who is your primary vendor for clinical supplies?*
- Atlanta Dental Supply
- Benco
- Goetze Dental
- Henry Schein
- Midwest Dental
- Nashville Dental
- Patterson
- Other

What are your practice goals in the next 12 months (check all that apply)*
- Reduce the amount of PPO write-offs
- Increase the profitablity of the practice
- Fill excess capacity
- Start-up practice intending to grow
- Add an associate dentist
- Add a new location
- Acquire an existing practice
- Begin accepting insurance

Please complete to receive your FREE Practice Analysis.
Practice Name*
NPI Number*
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Role*
- Owner/Dentist
- Associate Dentist
- Office Manager
- Other
Email*
Best Phone*
Best Contact Method*
Best days / times to call
How did you hear about us?*
Referred By:*
Comments
This field is for validation purposes and should be left unchanged.

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