Maverest Dental Alliance, Inc.

Dentists: Update Your Information

Return to the Dentist Center

Items in bold are required.

First Name
Last Name
Email Address
Degree
Specialty
Practice Name
Address
Ste/PO Box
City
State (Abbreviation, ie: FL)
Postal Code
Telephone (No spaces)
Fax (No spaces)
Tax Identification Number (No Spaces)
Enter this Code (No Spaces)	4a0c1



Please note that changes to the following must be accompanied by a physical copy on file with Maverest: DEA Expiration State License Number and Expiration Professional Liability Insurance Company and Expiration Please send these changes via fax or mail.
Also, If you notice that any of you credentialing information has been updated or you have received any of the licenses listed above within the past 4 months, please submit your new licensing information via mail or fax. Maverest must maintain a current physical record of all participating dentists. Dentists that are more than 6 months out of date will receive a reminder form in the mail. If you have any questions regarding your credentialing information, please contact us via e-mail or by phone.