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Request Provider Support

If you would like a call back from a provider network specialist, please complete the form below.

*Required Field

Requested By* 

Business Name* 

Office Address* 

  A separate form is required for different locations.
Provider Name* 

Office Phone* 

  Numbers only
Business Tax ID* 

  Numbers only
Provider License ID* 

  Numbers only

Indicate areas of interest     (Select all that apply)

 Using the Delta Dental of Arizona website, including the Dentist Connection
 Adding or removing providers
 Dentist contracts, filed fees and updates
 General credentialing issues
 Managing your NPI
 Participating dentist office visits
 Retrieving direct deposits
 Updating your business address
 Updating your tax ID

Please enter the form authorization code in the text box below.

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