Dentist Information Request

Online support for Delta Dental PPOSM and Delta Dental Premier® networks.

Step 1: The following online or automated services may have what you need. If not, go to Step 2.

Provider Tools:

Log in to your online account to view current eligibility and benefits information, remaining maximums and deductibles, claim status and treatment history and/or enroll in direct deposit.

Automated telephone system:

Hear current eligibility and benefits information, or request faxes (there is no limit to the number of faxes you can request per call). Choose the Customer Service number for your region here: deltadentalins.com/about/contact.

Step 2 - Tell us how we can help.

What would you like to do? (Select one)

I'm looking for new business opportunities.

Step 3 - Please include all the information requested below.

1. Select Plan options:

2. Business information to be contracted or affected by a change:

Type of business entity:

1099/IRS mailing address:

3. Practice location to be contracted or affected by a change:

Practice location address (Note:Practice location cannot be a PO Box):

4. Dentist to be contracted or whose information is to be changed:

5. Your contact information:

Thank you! You'll hear from us soon.

My current business information needs to be updated.

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