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Total Dental
Administrators, Inc.


Utah

6985 Union Park Center
Suite 675
Cottonwood Heights, UT 84047

Phone 801-268-9740
Fax 801-268-9873
Toll Free 800-880-3536

Arizona

2111 E. Highland Avenue
Suite 250
Phoenix, AZ 85016-4735

Phone 602-266-1995
Fax 602-266-1948
Toll Free 888-422-1995

Arizona Provider Enrollment Forms

 

Please download the form appropriate to your specialty.

Arizona Provider - General Dentist

Download General Dentist Form

Arizona Specialist - Endo Perio Oral Surgeon

Download Endo Perio Oral Surgeon Form

Arizona Specialist - Orthodontist

Download Othodontist Form

Arizona Specialist - Pediatric Dentist

Download Pediatric Dentist Form

Arizona Specialist - Prosthodontist

Download Prosthodontist Form