Allied Dental Health Professional (ADHP) Application

If you have questions concerning ADHP membership, please contact the Membership Department at 800-342-8747.

* Indicates a required field.

Profession*


 

First Name*
Middle Inital/Name
Last Name*
Designation
Gender

Email*

 

Office

Practice Name
Address
Suite or PO Box
City
State
Zip
Phone
Website

 

 

Home Address

Address
City
State
Zip
Phone

 

Professional Licensure or Certification

License Number or Certification Type
State(s)

 

Professional Interests.  Please forward me information on how to participate in the following:

 (including Yankee Dental Congress)   Dental Health Presentations 

 

Payment Method*

Annual membership dues are $35.
If you are employed in the office of a MDS member dentist, then membership is FREE.