Health and Human Services

Practice Registration

Please use this form to set up an online account for your dental practice(s). You will need to set up an account for each practice tax ID, with a unique email address.

Information should be entered for the primary user of the account. Additional users may be added to the account after set-up.

Primary User First Name

Primary User Last Name

Office Tax ID

Office State

Please choose your state from the drop down below

Primary user email address

Provider name

Dental license

Provider NPI