Original Questionnaire Responses
Q: Office EmailA: kjhgk@erfgw.com
Q: Practice NameA: kjh
Q: AddressA: kjh
Q: CityA: jkhkj
Q: StateA: kljhk
Q: Zip CodeA: 33987
Q: Office PhoneA: dfwgewg
Q: First NameA: sdfgsfd
Q: Last NameA: sdfgfsd
Q: DegreeA: DDS
Q: Area of PracticeA: General Dentist
Q: ExperienceA: 5-10 years
Q: Languages SpokenA: Spanish
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://wqerfqer.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: Yes
Q: Have you ever voluntarily relinquished hospital privileges, DEA Registration, academic appointments or any other professional status while an investigation was conducted?A: No
Q: Have any professional claim settlements, not involving litigation or arbitration, been paid by you or paid on your behalf?A: No
Q: Malpractice DocumentA:
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