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Customer Number*

Practice Name (DBA)*

Billing Provider Name (if different than Practice Name)

Address 1*

City*

State or Province*

Zip Code*

Billing Tax Identification Number (TIN)*

Billing National Provider Identifier (NPI)*

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HSPS will forward your request on to Denti-Cal & they will contact you with any
additional requirements needed in order to process electronically to them through
our Electronic Processor.

Please NOTE Denti-Cal requires your NPI to be registered, please visit www.denti_cal_ca.gov to ensure your NPI is registered with them.

Thank you,
the Henry Schein Payor Implementation Team