Apply to Join — Bitology Dental Network

CAQH & Specialty

We use your CAQH Provider ID for credentialing verification.

CAQH Provider ID *

Primary Specialty *

Provider Demographics

Personal and professional identification details.

First Name *

Middle Name

Last Name *

Suffix

Date of Birth *

Gender

SSN *

Individual NPI (Type 1) *

Organization NPI (Type 2)

Tax ID / EIN *

Primary Contact Email *

Primary Contact Phone *

Licensure & Certifications

State license and board certification details.

State License Number *

State of Issue *

License Expiration Date *

DEA Number

DEA Expiration Date *

Board Certification Status

Certifying Body Name *

Certification Expiration Date *

Practice Location & Billing

Where your practice is located and billing information.

Legal Business / Clinic Name *

Primary Practice Physical Address *

City *

State *

ZIP Code *

Office Phone *

Office Fax

Billing address is the same as physical address

Accepting New Patients

Office Hours

Malpractice / Liability Insurance

Current professional liability insurance details.

Insurance Carrier Name *

Policy Number *

Coverage Per Occurrence *

Aggregate Coverage *

Policy Expiration Date *

Document Uploads

Upload the required credentialing documents. Accepted formats: PDF, JPG, PNG (max 10 MB each).

State Medical / Dental License

Drag & drop or click to browse

DEA Certificate

Drag & drop or click to browse

Malpractice Insurance (COI)

Drag & drop or click to browse

W-9 Form

Drag & drop or click to browse

I hereby certify that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that any misrepresentation or omission may result in denial of this application or termination of my network participation.

Application Submitted!

PA-2026-0001

Your provider network application has been received. Our credentialing team will review your application and supporting documents. You'll receive an email notification when there's an update.

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Application Status

Our team is reviewing your application. You'll receive an email when there's an update.

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Provider Network Application

CAQH & Specialty

Provider Demographics

Licensure & Certifications

Practice Location & Billing

Malpractice / Liability Insurance

Disclosures & Attestation

Document Uploads

Application Submitted!

Application Status

Provider Network Application

CAQH & Specialty

Provider Demographics

Licensure & Certifications

Practice Location & Billing

Malpractice / Liability Insurance

Disclosures & Attestation

Document Uploads

Application Submitted!

Application Status

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