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Request for Dental Fee Schedule

Please provide the following provider information to receive a dental fee schedule.

Provider's Last Name:
Provider's First Name and Middle Initial:
Provider Tax ID:
Contact Name: (optional)
E-mail Address:
Confirm E-mail Address:
Provider State:	Utah Idaho
Provider/Contact Phone Number: (including area code)
Type of Provider:	Dental Medical-Oral Surgery
Oral surgery procedure codes: (enter codes seperated by a comma)
Contracted with Deseret Mutual:	Yes No