Aetna Dental Interest Form

Thank you for your interest in joining Aetna's Dental Network! Please fill out the form below and a network representative will reach out to you to discuss how we can work together.

Requestor Information

Submitter Name

Submitter Email

Dental Office Contact Name

If different from the submitter

Service Location Information

Dental Office Name

Tax ID

Street Address

City

State

Zip Code

Office Phone Number

Office Email

Please add any additional locations as an attachment to your request

Provider Details

Provider First Name

Provider Last Name

Individual NPI

Specialty

Please add any additional providers as an attachment to your request

Supporting Documents (optional)

Get the process moving! Attach your Usual & Customary rates or any other information relevant to your request

It is preferred to get Usual & Customary Rates in an Excel format

Request Comments

Please list any additional locations or notes specific to this request.