Update Your Office Information

Dentists Name: Office Phone: Fax Number: Date of Birth: (mm/dd/yyyy) Last Four digits of Social Security Number: Address: City: State/Zip: Email (required): Name of Office for Check Writing Purposes: Name: Address: City State/Zip: Federal Tax ID of Dentist/Practice for income tax purposes: Do you practice as part of a group or corporate office? Yes No If yes, please list names of corporation and Associate Dentists: Do you deliver care at more than on site? Yes No If yes please list: Effective Date of Change:

 

Superior Direct Connect provides benefit administrators direct access to our enrollment system to add new employee records or request new ID cards. All these capabilities are just a click away!