Client Liberty Dental Plan

If you would like to nominate a dentist and/or dental office to join the Dental Network, please complete the following information.

Please note that * indicates a required field.

Dentist's Name

Practice Name

Dentist's Address

City, State, Zip

Dentist's Phone Number

Your Name

Your Phone Number

Your Email Address

One of our Dental Recruiters will contact the dental office to see if they would like to join our network of participating providers. Please allow 4-6 weeks for recruitment efforts to be completed. Thank you for your nomination.