1. Benefit Plan
*
Please indicate who will be going to this office:
[Select One]
Adults Only (21 and over)
Children Only (under 21)
Both Adults and Children
2. Location
*
City,
County:
[choose one]
Alameda
El Dorado
Fresno
Imperial
Kern
Kings
Los Angeles
Madera
Marin
Merced
Monterey
Napa
Orange
Riverside
Sacramento
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
Santa Clara
Santa Cruz
Sonoma
Stanislaus
Tulare
Ventura
- Or -
*
Zip Code:
within:
5 miles
10 miles
15 miles
20 miles
25 miles
30 miles
3. Additional Search Criteria
Specialist Type:
General Dentist
Endodontist
Oral Surgeon
Orthodontist
Pedodontist
Periodontist
Prosthodontist
Your plan may only provide benefits if you obtain a referral from your General Dentist prior to receiving treatment from a Specialist. Please refer to your Evidence of Coverage prior to contacting a Specialist if you are unsure, or call Member Services
Dentist Last Name:
Office Name:
Office Address:
NPI #:
License #:
Language Spoken: