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Dental Plans
Providers

Provider Registration Form

Please complete the form below for your dental practice

Legal Business Name*

Primary Provider Name & Title (DMD, DDS...etc.)*

Federal Tax ID*

Office Contact Person

Address 1*

Address 2

City*

State*

Zip Code*

Primary Phone*

Alt Phone

Email*

Brite Plans, llc

1 Oakwood Boulevard, STE 200, Hollywood, Florida 33020, United States

(888) 292-7438 ely@briteplans.com

Copyright © 2019 Brite Plans, LLC - All Rights Reserved.