Dental Office Profile Update

Use this form to update specific information regarding your dental office. This information is used to accurately process and pay claims. In addition, it may be used in your provider directory listing. Note: You’ll need to fill out a separate form for each office location that has changes or updates.

Tips For Using This Tool

Use this tool when:

  • You need to update general information about your office hours, languages, website, phone or fax numbers
  • Your office's physical or billing address changed
  • Your office's general or billing email changed
  • You need to report a change to your NPI number
  • You had providers leave the practice location

Submit a new Participating Provider Agreement when:

  • You hired new dentists at your office
  • Your tax ID number changed
  • You purchased or opened a new dental office


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