Join the Aetna Dental®network

Please complete the form below to receive an application to join Aetna’s network.

All fields marked with a RED asterisk (*) are required in order to proceed.

1) Plans

Dental Maintenance Organization (DMO)®

Dental PPO/PDN*

DMO & PPO

2) Contact Information

*Name Of Dental Office

*Dentist Last Name

*Dentist First Name

Dentist Middle Initial

*Dentist Email Address

*Office Address

*City

*State

*Zip Code

*Phone Number

3) Practice Information

*License Number

*Tax Identification Number

Please enter numbers only, no dashes.

NPI Number

*Specialty

*In Texas, the Preferred Provider Organization (PPO) is known as the Participating Dental Network (PDN).

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