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Email You Used to Order

Full Names of ALL Dentists in Practice as Displayed on License

What is the sedation level on your certificate from the state?

Name of Practice

Address

Address 2

City

State

Zip Code

Practice Phone

Location of Oxygen

Location of Emergency Drug Kit

Location of AED

Practice Discipline

Patients Served

Procedures Performed

Highest Level Of Sedation License of All Providers in Practice:

Moderate Sedation IV sedation or General Anesthesia patients under 13?

Papoose Board Used

Practice Setting

EMS Availability

Certification of Local EMS Provider