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Nominate a dentist

You can nominate a dentist or dental office to join the Liberty network by submitting this form.

After you submit, one of our dental recruiters will contact the dental office to see if they would like to join our network of participating providers. Please allow four to six weeks for recruitment efforts to be completed. Thank you for your nomination.

Please complete all fields. Fields marked as optional can be skipped.

Coverage details

Dentist or practice details

Submitter details