Thank you for your interest in the CONNECTION Dental network. To view this application, you need the Acrobat Reader program. If you do not have Acrobat Reader, please click on the link provided below. The link will take you to the Acrobat Reader website and allow you to download Acrobat Reader free of charge.

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• CONNECTION Dental Application
  This application is to be used by all individual dentists. Click to download a copy of the Application.

Each Application must be submitted with all supporting documentation and a signed and completed Participating Provider Agreement. To request a Participating Provider Agreement, go to contact us. The following items should be collectively submitted to the CONNECTION Dental Network (keep a copy for yourself):

• Completed and signed Application
• Copy of Your Current State License
• Copy of Your DEA Certificate
• Proof of Malpractice Coverage (please include copy of the Certificate of Insurance or policy face sheet which reflects expiration date and malpractice limits)
• Completed and signed Participating Provider Agreement

You may fax this information to (816) 257-4439 or mail the information to:

CONNECTION Dental Network
P.O. Box 6707
Lee's Summit, MO 64064-6707