Dental Provider Update Form

This online form is for the providers who are directly contracted with Envolve Dental, DBA Centene Dental Services (CDS). All new Tax IDs will need a new application, and are subject to credentialing. The required application is available on our website at Join Our Network.

United Concordia providers: This form can’t be completed here. Please contact United Concordia for support.

Select all that apply * Add Credentialed Provider to a Location Add New Location to a Contracted TIN Update Current Location Terminate Provider from a Contracted TIN Terminate Location from a Contracted TIN Select at least one option.

Provider Information

Provider Name *

Provider NPI *

Payee Information

Payee Name *

Tax ID *

Payee Address *

Contact Information

Name of the person submitting this request *

Title of the person submitting this request *

Email * We may reach out to this email with questions.

Phone Number * We may reach out to this phone number with questions.

Current Location

Address to be terminated from

Address to be terminated

Location/Practice Name *

Location NPI *

Street Address *

Suite

City *

State *

ZIP *

New Location

New location to add the provider

Location/Practice Name *

Location NPI *

Street Address *

Suite

Phone *

Fax *

Email *

Please download the * roster file *, enter the required information, and upload the completed file in the section below.

Attach Roster *

Effective date for this change *

Please specify the reason for termination *

Any other comments

Submit Request

A PDF version of the application is also available as an alternative to this form.