Profile For Credentialing - Delta Dental
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1
2Dental Office
Office Profile for:
o Owner
o Associate
Profile for
Dr. ___________________
Credentialing
(Must be completed in its entirety)
Office Name: ____________________________________________ Corporate NPI (Type 2): _____________
(Doing Business Name As (DBA) to be listed in the directory)
Office Address: _________________________________ City/State/Zip: ______________________________
Payment Address
: _____________________________________________________
(if different from office address)
Telephone #: __________________ Fax #: ___________________ Office Manager: _____________________
Business Tax Identification Number
Business Name and TIN Number Must Match your IRS Issued Tax Return or
Coupon Payment Book
Business TIN: _____________________ Business Name: ___________________________________________
(Must Match the IRS Issued Tax Return or Coupon Payment Book)
An IRS/Dept of the Treasury document is required for verification of your Business TIN# and Name as listed
with the IRS. W-9 Forms are no longer accepted for verification. If you do not have an acceptable IRS form,
please have the Owner Dentist call the IRS Customer Service, (800-829-0115) and request a fax of the form
147C or SS4.
o Yes
o No
IRS/Dept of the Treasury Document for TIN is Attached
o Yes
o No
Social Security Number is being used on insurance claim forms in lieu of TIN
Enroll in Direct Deposit for Delta Dental of Illinois
• Quicker Payments
• No Cost to your Office
• Safe & Secure Delivery of Payment
• Electronic Posting of Payments (for compatible
• Explanations of Payments by Fax or Email
(practice management programs)
o Yes
o No
Direct Deposit Enrollment Form is attached.
Email Address: ____________________________________________ Publish in Directory: o Yes
o No
Website Address: www. _____________________________________ Publish in Directory: o Yes
o No
Special Office Hours (check all that apply)
o Mornings (before 8:00 a.m.)
o Evenings (After 8:00 p.m.)
o Weekends
Are you accepting new patients?
o Yes
o No
Is your office handicap accessible?
o Yes
o No
Does your office provide free parking?
o Yes
o No
Is the office near public transportation?
o Yes
o No
Does the office submit claims electronically?
o Yes
o No
Does the office have internet access?
o Yes
o No
Does your office have experience with special needs patients?
Adults
o Yes
o No
Children
o Yes
o No
Does your office offer treatment plans to all of your patients?
o Yes
o No
List any languages spoken in your office other than English: ____________________________
7389 (10/15)
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Parent category: Medical