Re-credentialing with Delta Dental of Idaho

1. Delta Dental of Idaho Credentialing Application
   • Complete all fields on the online app. Do NOT leave anything blank!
   • Anything left blank will be returned to you for completion
   • You may note "N/A", if appropriate
2. State Dental License or license renewal receipt
3. Drug Enforcement Administration (DEA) Registration, if applicable
4. Current Malpractice Insurance Declaration Page for your dental liability coverage,
   The declaration page must show your:
   • Name
   • Policy number
   • Coverage amounts
   • Dates of coverage

Becoming a Delta Dental of Idaho Network Dentist

1. Delta Dental of Idaho Credentialing Application
   • Complete all fields on the online app. Do NOT leave anything blank!
   • Anything left blank will be returned to you for completion
   • You may note "N/A", if appropriate
2. State Dental License
3. Drug Enforcement Administration (DEA), if applicable
4. Current Malpractice Insurance Declaration Page for your professional liability coverage,
   The declaration page must show your:
   • Name
   • Policy number
   • Coverage amounts ($1 million/$3 million required)
   • Dates of coverage

Join the Delta Dental Idaho PPO^®, Medicare Advantage Network, Value Added Orthodontic Discount Program, or Medicaid Network

PPO Network

• Complete and return the Delta Dental of Idaho contract addendum

Value Added Orthodontic Discount Program (Orthodontist only)

• Complete and return the Delta Dental of Idaho contract agreement

Medicare Advantage Network

• Complete and return the Delta Dental of Idaho contract addendum
• Credentialing Profile (part 1 & part 2)
• Work history statement (or CV) from the last 5 years
• Copy of malpractice insurance certificate
• Specialty certificate (if any) and/or hospital privileges (if any)
• Copy of the state license and DEA license

Medicaid Network