Dental Directory : Dentist Registration Form

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Dental Directory > Dentist Registration Form

Dentist Registration Form

The purpose of this website is to help parents, medical providers, and others to find dentists who will care for individuals with special healthcare needs and for young children.

Please use this form to register electronically or you may print this form and fax to (804) 864-7783 or mail to:

Kami Piscitelli
Virginia Department of Health - Division of Dental Health
109 Governor St., 9th Flr., Richmond, VA 23219
Phone: (804) 864-7804

Please Note: That you will need a valid email address to complete this form electronically.

Dentist Name

First Name*: MI: Last Name*:

Suffix: (e.g., Jr, Sr, III) Degree:

Office Address

Practice Name:
(if different from your name)

Primary Office Address:*

City:*

State:*

Zip:*

Phone:*

Clinical Hours: Definition

Practice Name:
(if different from your name)

Second Office Address:*

City:*

State:*

Zip:*

Phone:*

Clinical Hours:

Practice Name:
(if different from your name)

Third Office Address:*

City:*

State:*

Zip:*

Phone:*

Clinical Hours:

Practice Name:
(if different from your name)

Fourth Office Address:*

City:*

State:*

Zip:*

Phone:*

Clinical Hours:

Type of Practice*

General DentistryOrthodonticsProsthodonticsEndodontics
Pediatric DentistryOral and Maxillofacial SurgeryPeriodonticsOther
Other Practice Type:

Special Needs

Age of Patients

Do you treat children?YesNo

Payment Method(s) Accepted

Do you accept Medicaid? YesNo

Do you have a sliding fee scale?
(A sliding fee scale is one that is based on the patient's ability to pay.) YesNo

Languages other than English Spoken in Your Office

Tip: Hold down the control key and click to select multiple items.

Other Languages:

Additional Comments

The following information is for internal use only and will not be published on the website

Dentist Information**

* Indicates Required Field

** Indicates Internal use only

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For any questions, problems or needed corrections please contact Kami Piscitelli

Virginia Department of Health - Dental Health Program
109 Governor St., 8th Flr., Richmond, VA 23219
Phone: (804) 864-7804

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The following information is for internal use only and will not be published on the website

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