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NPI *

Facility Name *

First Name *

Last Name *

Physical Street Address -- NOTE:  Please return to complete this Survey separately for each physical service location where you provide dental services. *

Physical City *

Physical State (Please use state abbreviation ex: ME for Maine) *

Physical Zip Code *

Are you currently accepting new MaineCare members? *
Are you able to accommodate children with special needs? *
Are you able to serve children with mobility issues such as wheelchair ramps and wider doorways?
Are you able to provide services to children with complex health needs such as sedation?
Are you able to provide services to children with intellectual disabilities such as autism?
Dental License Number