Dental Provider Update Form

This online form is for the providers who are directly contracted with Envolve Dental, DBA Centene Dental Services (CDS). If you are contracted with United Concordia please reach out to them for support. 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.

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.