Dentist Request Form

Thank you for your interest in becoming a Maverest provider.
Please fill out the following information to request a membership packet from Maverest.

Note: Items in red are required.

First Name
Last Name
Email Address
Degree
Specialty
Practice Name
Address
Ste/PO Box
City
State (Abbreviation, ie: FL)
Postal Code
Telephone (No spaces)
Fax (No spaces)
Tax Identification Number (No Spaces)

Upon receiving your application packet, please complete the application in its entirety and be sure to sign. Also Maverest requires all dentists to submit via mail or fax the following licenses with valid expiration dates:

Form DEA - 223 (view)
State Dental License (varies by state)
Proof of Professional Liability Insurance (varies by company)

If you have any questions regarding which forms to submit, feel free to contact us via e-mail or by phone.