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Medical Care Plan
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*Provider Type:


*Provider Name:


*Provider Phone Number:


Street Address:


City:


State:


Zip Code:


Provider Web Address:


Provider Contact E-Mail Address:


Fax Number:


Your Name:


Your Phone Number:


Your E-Mail Address:


Comments:
Dental | Vision | Prescription | Hearing | Hospitalization | Medical | Chiropractic

The Dentex Plans are not Insurance. They are contractual arrangements made between Dentex and local or national healthcare networks to provide substantial negotiated savings to Dentex members. Please review our Important Terms and Conditions page for additional information.

For more information please call 1.800.400.0613.

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