Dental Care Alliance (DCA) - Office Enrollment Form

Please call (844) 597-7617 or email info@PristineMedicalBilling.com if you need any assistance with the following form.

Practice Name

Group Practice Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Practice Phone

(###)

###

####

Website

http://

Section

Doctor Name

Doctor email address

Individual NPI Number

State License Number

Tax ID Number

Preferred Office Contact Name

Preferred Office Contact Email