Have you submitted your application for RX writing and referring patients out to specialist?  Attached is a list that you should use to guide you.

Information necessary to submit application for ordering and referring practitioner:


Ideally the application should be done online, please provide the login information you received when your individual National Provider Identification (NPI) number was issued to you, it will be on the letter you received issuing your NPI.

If you cannot locate this information, you may obtain your user name and login password by contacting:



A paper application can be submitted if you are unable to locate the login.


Please provide the following information so your application can be submitted and processed in a timely manner:


Your Legal Name:

First: _________________________ MI ___  Last:___________________  DDS or DMD

Have you any alias?  If yes, please provide:

First: _________________________ MI ___  Last: ___________________ DDS or DMD

Have you ever gone by another name? (maiden/professional)

First: _________________________ MI ___  Last: ___________________

Mailing Address: _________________________  City: ________ State: ____ Zip: _____  Telephone # ______________________  Fax #:_______

Email: _________________________

Legal Business Name on file with IRS: ______________________________________

Your social security # ________________   Date of Birth: _____________  M__ F__

Individual NPI: ______________________

What Dental School did you attend/graduate? ______________________________

Year of graduation: _____________

Professional License number:_______________   State: ______________

Effective date: __________ exp date:______

Do you hold a DEA Certificate? Y__ N__  registration # _________________

Effective date: _____________________   State: ___________


Have you had any final adverse legal action taken against you? Y___ N___ if yes:

Action: ____________________________________________  Date: ____________

Taken by: __________________________________________________________

Resolution: _________________________________________________________

Christine Taxin
36 Abington Avenue
Ardsley New York 10502
United States of America