Original Questionnaire Responses
Q: Office EmailA: cbkv
Q: Practice NameA: kcbv
Q: AddressA: kcvb
Q: CityA: ckvb
Q: StateA: vckb
Q: Zip CodeA: kcvb
Q: Office PhoneA: kcbv
Q: DegreeA: DMD
Q: Last NameA: ckvb
Q: First NameA: ckvb
Q: ExperienceA: 0-5 years
Q: Area of PracticeA: General Dentist
Q: Languages SpokenA: English
Q: How many new patients are you looking for monthly?A: 16-30 new patients
Q: Ready to Start Receiving Matches?A: I'd like to learn more about the process first
Q: URLA: https://kcbv.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: Yes
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: Yes
Q: Have your hospital privileges, if any, ever been revoked, suspended, reduced, or not renewed; have disciplinary proceedings ever been instituted against you; or are any of these actions now pending with respect to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: Yes
Q: Have you ever voluntarily relinquished hospital privileges, DEA Registration, academic appointments or any other professional status while an investigation was conducted?A: Yes
Q: Have any complaints been filed against you with a dental/professional society? A: Yes
Q: Have any professional liability judgments been entered against you, including arbitration awards or are there professional liability suits currently pending against you?A: Yes
Q: Have any professional claim settlements, not involving litigation or arbitration, been paid by you or paid on your behalf?A: Yes
Q: Has your professional liability insurance ever been canceled or has professional liability insurance ever been denied? ®Yes ®NoA: Yes
Q: Have you ever been convicted of a felony or do you have any felony or misdemeanor charges pending (other than minor traffic offenses)?A: Yes
Q: Do you now have or have you had a chemical dependency/substance abuse problem?A: Yes
Q: If you answered "Yes" to any of the questions above, please provide a detailed explanation, including the outcome. If you prefer to submit supporting documentation, you may email it to credentials@matchmydentist.com. A: jf
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