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Become a Provider

Providers: Join The Health Net Dental Network

Step 1

Please complete, sign, and date a Provider Credentialing Application (PDF)
(required for all practicing Dentists and Associates)

Step 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)


Please also submit Specialty Certificate(s)

Step 3

Mail forms to:

Provider Relations
340 Commerce, Suite 100
Irvine, CA 92602


Last Updated: 02/03/2023