ERA Enrollment Form

Welcome to the DentaQuest Online Electronic Remittance Advice (ERA) Enrollment Request page. Please be sure to complete all of the required fields (marked with a star) and click on Submit before leaving this screen. Partial entries will not be saved.

Provider/Organization/Practice Identification

Provider Name

Doing Business As Name (DBA)

National Provider Identifier (NPI)

Provider Federal Tax Identification Number (TIN)

Organization/Practice Contact Person

Provider Contact Name

Phone

Organization/Practice Address

Address (Street Address or PO box)

Address 2 (Suite number, etc.)

Yes No

Preference for Aggregation of Remittance Data (e.g. Account Number Linkage to Provider Identifier)

Please choose aggregation type based on the identification used by your receiving bank on your bank account. If you are identified on your bank account by TIN, please choose TIN. If by NPI, please choose NPI. If you are identified by TIN, please do *not* choose NPI. The aggregation type must match your banking institution’s identification on your bank account.

PREVENTISTRY PULSE

The newsletter designed for anyone who wants to improve oral health for themselves, their families, customers or communities.