Nominate Dental Provider

If the dentist of your choice is not part of the Ameritas network, you may nominate them to join by completing the form below. Completing the form does not guarantee acceptance into the network. The nomination process is approximately 45 days.

Click here to check if your dentist is a member of our network:

Your Information

Name (Required)

Street Address (Required)

City (Required)

State (Required)

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Zip Code (Required)

Phone Number (Optional)

Email Address (Optional)

Provider Information

Provider Specialty (Required)

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Provider Name (Required)

Name of Practice (Optional)

Street Address (Required)

City (Required)

State (Required)

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Zip Code (Required)

Phone Number (Optional)

Email Address (Optional)