Tell Us About Yourself
* Email Address
* First name
* Last name
* Professional title
--Select One--
D.D.S.
D.M.D.
* Address
(line 2, if necessary)
* City
* State
--Select One--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip
Business Phone
Home Phone
Cell Phone
Fax Phone
* Dental School
Year Graduated
Primary License Number
* What is your specialty?
--Select One--
GP
Endodontics
Orthodontics
Oral Surgery
Pedodontics
Periodontics
Prosthodontics and Implant dentistry
Other
* Do you have a MEDICAIDE PROVIDER number?
--Select One--
Yes
No
Below, please check EACH state in which you hold a valid license. PLEASE NOTE: REGIONAL
certification (NERB, for example) still does NOT permit you to practice dentistry in
any state unless and until you hold a valid license issued by that specific state
dental board. (Personally, we think that's absurd , and it costs us money every day...
but it's the law....)
* Are you willing to sometimes travel to 'long-distance' locations if your lodging and travel expenses are paid?
--Select One--
Yes
No
* Has your license to practice dentistry ever been suspended or revoked or have you ever faced disciplinary action by ANY state dental board?
--Select One--
Yes
No
* Are you seeking a locum tenens (temporary), regular part-time or a permanent position?
--Select One--
Temporary
Permanent
Regular P/T
TELL US ABOUT YOURSELF - Sell us your 'sizzle'
Use
the box below to write a paragraph, or two, or three about yourself,
your experience and your skills. Write it so that whoever reads it will
want to hire you immediately! What you write WILL
be posted on this website but your name and contact info will NOT be
posted. You will only be identified by a random number. (Anyone
interested in hiring you will have to FIRST call us. We
screen those parties for you and verify their interest and their opportunity.)
PLEASE DO NOT INCLUDE any personally-identifying data such as your phone number,
email address or where you work now, or how to contact you directly.
That leaves us out of the loop!
What you write is reviewed for such personally-identifying information before it is
posted to this website and if found, disqualifies you - immediately -
from consideration for membership.
CAUTION: WE DO NOT CORRECT YOUR SPELLING ERRORS...SO YOU SHOULD!
* Tell us about yourself
No need to explain, but please list which procedures you do NOT like to perform
And which procedures are you more than happy to and very efficient at performing?
If you are seeking a temporary or P/T position, what days of the week are you REGULARLY available? Please select Yes or No For each day.
Available Monday?
--Select One--
Yes
No
Available Tuesday?
--Select One--
Yes
No
Available Wednesday?
--Select One--
Yes
No
Available Thursday?
--Select One--
Yes
No
Available Friday?
--Select One--
Yes
No
Available Saturday?
--Select One--
Yes
No