Thank you for your interest in becoming a Dentistry Unchained provider. We are constantly screening new providers to offer high-quality service to our members. Please complete the following short application, and we will be in touch if it appears that our members and your services are a good match.


1. Tell us about you.

Full Name*

Company*

Phone*

Your Email*

Your Industry*

* Indicates a required field.


2. Provide three initial customer references that have experienced your high-quality standards.

Reference #1

Full Name*

Practice*

Phone*

Reference #2

Full Name*

Practice*

Phone*

Reference #3

Full Name*

Practice*

Phone*

* Indicates a required field.


3. Tell us how you might serve our members.

Discount Level*

If selected “other” please specify

* Indicates a required field.