Address change, sale of practice and Tax Identification Number (TIN) enrollment forms

Dental offices must notify the Dentist Network Administration and Contracting department in writing when the dentist:

• Opens or closes an office location
• Changes his or her name
• Changes address
• Buys or sells a practice (Notification of Sale of Practice form required when Accounts Receivable has been purchased)

A TIN Enrollment form is required when the dentist:

• Adds a new practice location
• Makes any changes to the tax identification number or changes to the type of business entity, e.g. partnership or corporation

The tax identification number and practice name on file with Delta Dental must match IRS records.

Click here to download forms (requires Adobe Acrobat Reader):

• Notice of Address Update

• Notification of Sale of Practice

• TIN Enrollment

Send forms to your local Delta Dental:

Attention: Dentist Network Administration and Contracting Department
Delta Dental of California, MS 5E
100 First Street, San Francisco, CA 94105
Fax: (415) 543-6326

Attention: Dentist Network Administration and Contracting Department
Delta Dental Insurance Company
PO Box 1809
Alpharetta, GA 30023

Attention: Dentist Network Administration and Contracting Department
Delta Dental of Pennsylvania
One Delta Drive
Mechanicsburg, PA 17055