Free Advertising for Dentists

Dental Listing and Web Site Request Form

and filling-out our application is completely online and takes just a few minutes.

Don't have a Web page?
Get some information on our Dentist Web Sites with guaranteed results.

Instructions
Just complete the dentist listing application by typing or selecting your answers. To submit the application, press the "I Agree" button at the end of the questionnaire. We can also email you an application. If you have questions or if you have problems completing the form, please send us email. The password is a value that you must make up. Your name will be added to our database absolutely FREE! However, you must have a valid email address! If you email address is not valid, we reserve the right to immediately de-active your listing. In addition, we reserve the right to send you an e-mail from time-to-time to check the validity of your e-mail address.

Once you have submitted your application, visitors will normally be able to conduct a search and see your company's name from our database in about 10 business days.

Password: Please save this information, it is required for you to make future corrections to your entry.
Submission Type:	Add A Dentist to the Searchable Database Contact us, we want an Enhanced Web site.
Name of Dentist:	First:	Middle:	Last:
Degree:
Dental License #:		Dentist's ADA #:
Are you Board Certified:		Are you Board Eligible:
Dentist's Date of Birth:		Dentist's Sex:
Dentist's Office Address1:
Address2:
City:		State: Zip Code:
County:
Phone Number:		Fax Number:
Dentist's Email (required):	Type the address as if you were emailing to this location
Dentist's Web Page Address:	Type the address as if you were browsing to this location
Dentist School:		Graduated:
Specialty School:		Graduated:
Toothpick affiliated associations:
Other professional dental associations: (limited to 255 characters)	ADA Warning: The program will "truncate" your list after 255 characters (incl. spaces).
Board Certified Dental Specialty:	To select multiple, hold down the CTRL key while clicking with the mouse	Other Un-Certified Expertise:	To select multiple, hold down the CTRL key while clicking with the mouse
Choose the Payment Methods you accept:	None Cash AmExpress BankOne DenCharge Discover Payment Plans Dental Insurance Sears Visa/MasterCard Others, please send us email for consideration
Number of Total Dentists in Office:		Number of Total Hygienists in Office:
Hours of Operation:
Special Language Spoken by Dentist:	Others, please send us email for consideration To select multiple, hold down the CTRL key while clicking with the mouse
Special Dental Equipment:	Others, please send us email for consideration To select multiple, hold down the CTRL key while clicking with the mouse
Special Entertainment:	Others, please send us email for consideration To select multiple, hold down the CTRL key while clicking with the mouse
Insurance Not Accepted:	Denti-Cal
Average Wait time for Dentist Appt.		Average Wait time for Hygienist Appt.
Choose up to 5 special dental keyword services you offer (Sorry, only the first 5 will be accepted):	Bleacing Ceramic Braces Clear Braces Colored Fillings White-fillings
	Cosmetic Dentures Partials Porcelains Reshapping Bonding Veneers
	Bridges Crowns Implants Jackets Root Canals
	Senior Discount Coupons Family Oriented Family Practice Free Parking Pain reduction
	Gum Infections Gum Treatment Preventative Extractions
Enter a Short Description of Your Dental Practice and Dentist Services (must be less than 255 characters). See the Rules.
, Warning: The program will "truncate" your description after 255 characters (incl. spaces).
Enter Short Driving Directions from the nearest major intersection (must be less than 255 characters). See the Rules.
, Warning: The program will "truncate" your directions after 255 characters (incl. spaces).
Use the following space to list any specific comments or questions that weren't in the FAQ's.


Attention: We will only accept a listing once. All duplicates are deleted from the database. Please check your input to ensure it is correct before pressing the "Submit button". Because of security reasons, all entries are modified by hand and corrections will incur a nominal charge on a per incident basis. By pressing the "Submit button" and adding your entry, you acknowledge that you have read, understood,and agree to be bound by our legal disclaimer.
Thank You!

Dental Listing and Web Site Request Form

NEW Dentist Submission Form