Provider Forms
For members eligible with one of NDB’s managed care plans, a NDB General Dentist Provider must complete a “Request for Specialty Referral” form and submit to NDB for review. Please follow the submission instructions on the back of the form. The forms for each area of specialty can be found below:
Request for Specialty Referral – Endodontics
Request for Specialty Referral –
Oral Surgery
Request for Specialty Referral - Orthodontics
Request for Specialty Referral – Pediatric Dentistry
Request for Specialty Referral – Periodontics
Request for Dental Services Provided in a Hospital or Surgery Center (Combined Medical Dental Form)
If you are a NDB Participating Provider and you would like to add an associate to your practice, please complete the following credentialing form and mail to:
Nevada Dental Benefits, Ltd.,
Attn: Credentialing,
6543 S. Las Vegas Blvd., 2nd Floor,
Las Vegas, NV 89119.
If you need to update your office information, please complete the following Practice Profile form and contact a Professional Networks representative at (702) 478-2014.
