Original Questionnaire Responses
Q: Office EmailA: office4@matchmydentist.com
Q: Practice NameA: miami dental
Q: AddressA: 123 main
Q: CityA: miami
Q: StateA: fl
Q: Zip CodeA: 33009
Q: Office PhoneA: 2131231232
Q: First NameA: tom
Q: Last NameA: JONES
Q: DegreeA: DDS
Q: Area of PracticeA: Specialist
Q: ExperienceA: 0-5 years
Q: Languages SpokenA: English
Q: How many new patients are you looking for monthly?A: 6-15 new patients
Q: Ready to Start Receiving Matches?A: Yes, I want to start as soon as my profile is approved
Q: URLA: https://WWW.MATCHMYDENTIST.COM
Q: Has your license to practice in this state or any other state been denied, restricted, limited, suspended or revoked; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license?A: No
Q: Has your DEA Registration ever been restricted, limited, suspended or revoked, or are any of these actions pending with respect to your DEA Registration?A: No
Q: Have your hospital privileges, if any, ever been revoked, suspended, reduced, or not renewed; have disciplinary proceedings ever been instituted against you; or are any of these actions now pending with respect to your hospital privileges?A: No
Q: Do you now have or have you had a chemical dependency/substance abuse problem?A: No
Q: Malpractice DocumentA:
View DocumentQ: DEA CertificateA:
View DocumentQ: State Dental LicenseA:
View DocumentQ: Only the doctor may complete and certify this form. Are you the doctor personally completing this form?A: Yes
Q: By clicking "I accept" below, you agree to the above certification terms and conditions and consent to electronic signatureA: Yes