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Free Practice Assessment
Free Practice Assessment
Susie Oliver
2021-10-29T07:30:33-04:00
Free Payer Assessment
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?
*
Please choose one
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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?
*
Below 10%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Role
*
Owner/Dentist
Associate Dentist
Office Manager
Other
Email
*
Best Phone
*
Best Contact Method
*
Email
Phone
Best days / times to call
How did you hear about us?
*
Please select referral type
AAWD
AADOM
Atlanta Dental Supply
Goetze Dental
Kleer
MidWest Dental
Nashville Dental Supply
Conference
Dental Consultant
Direct Mail / Postcard
Internet Search
Marketing Firm
Peer Referral
Social Media
Trade Organization
Referred By:
*
Email
This field is for validation purposes and should be left unchanged.
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