Dental Assistant Registration Application Packet

Dental Assistant Registration Application PacketContents: 1. 642-004 ..Contents List/SSN Information/ Mailing Information ..1 page2. 642-005 .. Application Instructions Checklist ..3 pages3. 642-006 .. Dental Assistant Registration Application ..4 pages4. 642-013 ..Out-of-state Credential Verification ..2 and Online Website Links ..1 pageImportant Social Security Number Information:You are required by state and federal law to provide a social security number with your Application . If you do not have a social security number at the time you send in this Application , please read, complete, and return this form with your Application . A Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance Number (SIN) cannot be order to process your request:Mail your Application with initial documentation and your check Send other documents not sent or money order payable to: with initial Application to:Department of Health Dental Quality Assurance Commission Box 1099 Credentialing Olympia, WA 98507-1099 Box 47877 Olympia, WA 98504-7877 Contact us:360-236-4700To request this document in another format, call 1-800-525-0127.

Please call the Customer Service Center at 360-236-4700 if you do not have one. National Provider Identifier Number (NPI):The National Provider Identifier (NPI) is a standard unique identifier for health care professionals available from the ... Dental Assistant Registration Application Packet

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