Provider and Office Information for Sleep Physician Portal and More Information on Mini-Residency

Please fill out each field to the best of your ability. The provider cell phone and e-mail in addition to the office e-mail are utilized for log in verification for the sleep physician portals. Please make sure they are accurate. By signing up for the sleep physician portal, you will receive the first 10 cases at no cost as you start screening and referring patients. After 10 cases, you can continue on the portal at a DDS discounted rate of $480/year. By selecting that you are interested in the Mini-Residency, you agree to receiving communications on upcoming courses and events from Dynamic Dental Sleep, LLC.

Provider Name(Required)

Provider Credentials(Required)

Provider Email(Required)

Provider Cell Phone(Required)

License Number(Required)

Office Phone(Required)

Office Email(Required)

Office Location #(Required)

Office Name(Required)

Office Contact(s)(Required)

Yes

Interested in Dental Sleep Medicine Mini-Residency(Required)

Yes

Office Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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