Nominate a Dentist

Nominate a Dentist to the GEHA Connection Dental^® Network

If the dentist of your choice is not listed in the directory, you may complete this form to nominate the dentist to participate in the GEHA Connection Dental Network. An application packet and information about the network will be sent to eligible providers.

If your dentist chooses to join the network, the normal time frame to complete the nomination process is approximately 60 days. All fields are required unless marked as optional.

Dentist Information

Name

Address

Additional Address (optional)

City

State

ZIP Code (optional)

Phone (optional)

Specialty (optional)

Member Information

Name (optional)

Address (optional)

Additional Address (optional)

City (optional)

State (optional)

ZIP Code (optional)

Phone (optional)

Email Address (optional)

Employer

Insurance Company

Comments (optional)

To speak to an Account Specialist about your nomination, please call 877.277.6872.

Thank you for helping to grow the Connection Dental Network.

Nominate a Dentist