Prospective Provider

Please fill out the information below.
A representative from Healthplex's Provider Relations department will contact you.

Practice Information

Practice Name

Street

City

State

Zip

Phone

Fax

Email

Practice Tax Id #

Interested In

Office Hours

Days of the Week

From

To

Sunday

-

Monday

-

Tuesday

-

Wednesday

-

Thursday

-

Friday

-

Saturday

-

Please note special hours here

Dentists and Specialty

Please list dentists and their specialty

First

Last

MI

Specialty

NPI

License