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Personal Information

First Name

Last Name


School Attended

Degree Received


Grad Year

Personal Email Address

Office Details

Office Street Address

Office City

Office State

Office Zip

Office Phone

Office Fax

Office Name

Office Contact

Office Email

Office Website

Office Hours

Monday Friday
Tuesday Saturday
Wednesday Sunday
Thursday Holidays

Specialties

Spoken Languages

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Additional Information

Do you offer a Payment Plan?
Are you a member of the American Dental Association?
Do you treat children?
Do you treat disabled children or adults?
Do you have a hygienist?
Do have a Lab on Premises?
Do you accept Medicaid?
Do you take emergency visits?
Is your office equipped to treat wheelchair bound patients in their own wheelchair?
Is your office accessible via public transportation?
Is your office equipped with auxiliary aids and services
(TTYIT DD, Braile, ASL, etc...)?
Does your office comply with OSHA requirements?
Does your office utilize proper infection control and barrier techniques?

Do you work on any of the following procedures (Please check the ones you work on):

Other, please indicate:

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Universal Dental Plan is not dental insurance. This plan does not meet minimum creditable coverage requirements under Massachusetts Law. The plan provides discounts at specific dental providers for dental services. The plan does not make payments directly to the providers of dental services. Plan members are obligated to pay for all dental care services but will receive a discount from those dental care providers who have contracted with the discount dental plan organization. The range of discounts will vary depending on the services provided. For questions concerning the Plan, including a list of network providers, please contact Universal Dental Plan: 20 Park Plaza 4th Floor, Boston, MA 02116. 1-800-894-8984, www.universaldentalplan.com, info@universaldentalplan.com.