Become a Dental Provider

Thank you for your interest in becoming an Envolve Benefit Options Dental Provider. The following information is needed to process your request for panel participation. Please complete this form below for our Network Management Department.

Correspondence Address (If Different from above)
Products you are interested in participating with:*

Please provide an Email address and Phone number we can contact you  in response to your request.

Upon receipt of your request for participation, a Provider Participation Agreement (PPA) & Fee Schedules will be mailed to your office for your review and execution.