Maverest Dental Network Directory - Encoreconnect

Maverest Dental Alliance prides itself in having the best dentists a dental network can offer. If you know a
dentist who would like to become part of Maverest’s group of dentists, please fill out the following form.
Requests can also be made at www.maverest.com.
Request for Dental Participation
Dentist Name:
Practice Name:
Street Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Employee Name:
Street Address:
City:
State:
Zip Code:
Employer Name:
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Maverest Dental Alliance will provide a packet of information to the dentist listed above, based on your request. Maverest will also
make additional contacts within 30 days of mailing the packet. Follow up contacts will be made by phone or personal visit. The
complete process (typically) takes between 60 and 90 days from first contact to fully enroll and credential a new dentist. Please
visit www.maverest.com to check status on any dentist requested we contact.
Please fax this request to Maverest at: 317-899-4270 or mail to:
Maverest Dental Alliance, Inc.
P.O. Box 0620
Indianapolis, IN 46250
Maverest Dental Alliance, Inc. l E. 75th Street l Suite 200 l Indianapolis, Indiana 46250
P.O. Box 50620 l 1-888-727-8598 l Fax (317) 889-4270