Become a Provider

Providers: Join the Health Net Dental Network

1. Please complete, sign, and date a Provider Credentialing Application (PDF) (required for all practicing Dentists and Associates)
2. Please submit current credentials (required for all practicing Dentists and Associates).
   
   General Dentist
   • Wallet size Dental License
   • DEA Certificate
   • Professional Liability
   • W-9 form (PDF)
   Specialists
   Please also submit Specialty Certificate(s).
3. Mail forms to:
   
   Provider Relations
   340 Commerce, Suite 100
   Irvine, CA 92602
   1-888-273-2713