| Dental Essential Community Providers |
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| All fields marked with an asterik (*) are required. To validate the template, press the validate button or Ctrl + Shift + V. To finalize the template, press the finalize button or Ctrl + Shift + F. |
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| If the contracted provider does not have an NPI, please leave the field blank. |
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| Provider Name must be unique. |
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| If you do not qualify for the alternate ECP standard, select from ECP Category and select NA for Provider Type. |
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| If you qualfy for the alternate ECP standard, select from Provider Type and select NA for ECP Category. |
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| Click the Display Network IDs button (or press Ctrl + Shift + N) to display the networks in the drop-down box in the Network IDs column based on networks listed in the Network ID template. |
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| Company Legal Name* |
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| HIOS Issuer ID* |
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| Issuer State* |
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| National Provider Number (NPI) |
National Provider Name |
Issuer Type* |
Provider Type* |
ECP Category* |
Street Address* |
Street Address 2 |
City* |
State* |
Zip* |
On ECP List?* |
Network IDs* |
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[General Standard Issuer or Alternate Standard Issuer] |
[Alternate Standard Issuers only] |
[General Standard Issuers only] |
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Optional |
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