10/3/23 Webinar Registration - Let’s Talk About Dental Medicaid

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* 1. Prefix (select one from dropbox)

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* 2. First Name:

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* 3. Last Name:

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* 4. Professional Credentials:

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* 5. Email Address:

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* 6. Are you currently a Medicaid provider?

Yes

No

In the process of enrolling

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* 7. If you are a Dental Medicaid Provider, please list the County(ies) in which you practice:

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* 8. What question(s), if any, do you have about Dental Medicaid that you would like discussed on the call?