Dental Health Alliance - Dentist Nomination

Nominate Your Dentist

To nominate your dentist for DHA membership, please complete the following information and send to us. We will contact your dentist for consideration in our PPO network.

*Dentist First Name:
*Dentist Last Name:
Practice Name:
Specialty:
*Dentist Address:

*City:
*State:
*ZIP:
*Dentist Phone:

*Your Name:
Your Employer's Name:
Thank you for your nomination.
*Required Fields