SpecialistsRegistrationPlease fill this form out to register your practice to be matched with a specialist.Personal Information Name * First Name Last Name Title (DDS, DMD) Email * Mobile phone number * Practice Street Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Professional Information Your primary specialty * Oral Surgery Periodontics Surgical Prosthodontics Your secondary specialty (if applicable) Oral Surgery Periodontics Surgical Prosthodontics Primary State of Licensure * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois State License Number * State License Expiry Date * MM DD YYYY Please check each of the following services you feel comfortable delivering Full Arch (Restoration) Full Arch (Surgery) General Anesthesia/IV Implant Placement Implant Restorative/Prosthetic C&B Laser/LANAP PRP Surgical Extractions (Most 3rds) TMJ/Myofacial Have you had any issues (suspensions, for example) with your license? If so, please explain here Your daily production goal (in dollars, for example $8,000) * $ Do you require Visa Sponsorship? How did you hear about us? * Craigslist DDS Dental Nachos Dental Shopper DentalPost DentistJobCafe DP E-mail Facebook Healthgrades HR Job Indeed Indian Dental Association Instagram LinkedIn Other Pair Dental Progressive Purchased List Seamless AI Search Engine Word Of Mouth ZipRecruiter * By registering as a Practice member of Alliance Dental. (“Alliance”), I understand that Alliance Dental Services will attempt to find suitable treating providers to match with my practice. I agree that any providers introduced by Alliance Dental Services are confidential and, before I work with a matched provider, I will need to sign additional agreements with Alliance Dental Services & the treating provider. I agree that I will not circumvent Alliance Dental Services and will not work directly with a matched specialist without signing the additional agreements. I understand and agree that any circumvention can lead to a lawsuit in the Superior Courts of San Francisco county. I accept Thank you!
