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Total Dental
Administrators, Inc.


Utah

969 East Murray Holladay Road
Suite 4E
Salt Lake City, UT 84117

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

Utah Provider Enrollment Forms

 

Please download the form appropriate to your specialty.

Utah Provider - General Dentist

Download General Dentist Form

Utah Specialist - Endo Perio Oral Surgeon

Download DHMO General Dentist Form

Utah Specialist - Orthodontist

Download DHMO Specialist Form

Utah Specialist - Pediatric Dentist

Download PPO General Spec Form