https://nppes.cms.hhs.gov/IAWeb/register/startRegistration.do

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: _________________________________________________________