You’re Almost There.

Once you fill you this quick form, our team will verify your insurance information and send you a link within minutes.

Self pay patients will receive a call to collect a $52 nominal fee.

Name

First Name

Last Name

What Dental Insurance do you have?

Presbyterian

Molina

Blue Cross Blue Shield of NM

Delta Dental of NM

No Dental Insurance

Insurance Not Listed

If insurance not listed, please enter the name of your insurance below:

Member/Subscriber ID:

Date of Birth

YYYY

Please include either email or phone number as it is how you will receive your link.

Phone

(###)

###

####

Where would you like to recieve visit link?

Phone

How did you hear about us?