Dentist Info Update Update your listing Company Only fill out the information you want to change and anything with an asterisk* What types of pediatric crowns do you currently use? NuSmile Zirconia NuSmile Signature NuSmile SSC How many dentists are applying? 1 2 3 4 5 6 Dentist First Name * Dentist photo Add a photo of the dentist. Please try to keep under 2 MB. Dentist Last Name * Dentist License Number * For identification and order history Pediatric Specialist Pediatric Specialist General dentist that treats children Practice Name Logo for Practice Add the logo for the practice. Please try to keep under 2 MB. Contact's Name Contact's Email Contact's Number Can we use your contact email to send you notifications? YesNo How many locations? 1 2 3 Street Address Address Line 2 City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Postal / Zip Code Practice Phone Number Website Link to book an appointment Insurance Plans You Accept 1 Traditional Insurance Aetna Dental Pro Ameritas PPO CHIP (Children's Health Insurance Program) Insurance Plans You Accept Cigna Dental PPO Delta Dental PPO Medicaid MetLife PDP Add Additional Plans Below Additional Insurance Plans Describe your practice By checking the submit button on this form, and if I qualify for a listing on the I Love My NuSmile website, I consent to NuSmile listing myself and my practice as an I Love My NuSmile Dentist on NuSmile’s dentist locator website (ilovemynusmile.com). I hereby indemnify and hold NuSmile harmless against, and release and discharge NuSmile from, any and all claims and demands arising out of or related to this listing or any services I may provide to any patient as a result of this listing, including but not limited to any and all claims for professional negligence and/or defamation brought against NuSmile, the listed person, or such person’s practice by any patient of the listed person (or parent/guardian thereof). I have the full power and authority to establish this listing. * Yes No You must answer this in order to submit the form name * email address * Comments / Questions
