INSURANCE FEE MAXIMIZATION

Principal: Most Recent Effective Date Request

PRACTICE INFORMATION:
Practice Name (required)

Name of Contact Submitting Request (required)

Email of Contact Submitting Request (required)

Phone Number of Contact Submitting Request (required)

PROVIDER REQUESTING ACTION:
First Name of Dentist (required)

Middle Name of Dentist

Last Name of Dentist (required)

Specialty (required)
---General DentistDental AnesthetistEndodontistOral Maxillofacial SurgeonOrthodontistPediatric DentistPeriodontistProsthodontist

Provider NPI# (required)

Provider Tax ID Number/TIN (required)

Once submitted, the request will be sent to Principal for your Provider's Most Recent Effective Date. You will receive an email from Principal with this information.