First Name * Middle Initial Last Name *
Address Type Home Office *
Address 1 *
Address 2
City * State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY * Zip Code *
Contact Number Work Mobile Home *
Best Time To Call *
E-mail *
I am a Dentist not a Dentist a Student * My Specialty is General Practice Endodontics Oral Surgery Orthodontics Pediatric Dentistry Periodontics Prosthodontics *
Dental School Arizona School of Dentistry Baylor College of Dentistry Boston University Case Western Reserve University Columbia University Creighton University Dalhousie University Emory University Fairleigh Dickinson University Foreign Georgetown University Harvard School of Dental Medicine Howard University Indiana University Loma Linda University Louisiana State University Loyola University Loyola University - Chicago Marquette University McGill University Medical College of Georgia Medical University of South Carolina MeHarry Medical College Midwestern University New Orleans Dental College New York University Northwestern University Dental School Nova Southeastern University Ohio State University Oral Roberts University Oregon Health Sciences University Southern Illinois University St. Louis University State University of NY at Buffalo State University of NY at Stony Brook Temple University Tufts University University of Alabama University of Alberta University of British Columbia University of California - Los Angeles University of California - San Francisco University of Colorado University of Connecticut University of Detroit Mercy University of Florida University of Illinois at Chicago University of Iowa University of Kentucky University of Laval University of Louisville University of Manitoba University of Maryland University of Medicine & Dentistry of NJ University of Michigan University of Minnesota University of Mississippi University of Missouri - Kansas City University of Montreal University of Nebraska Medical Center University of Nevada - Las Vegas University of North Carolina Chapel Hill University of Oklahoma University of Pennsylvania University of Pittsburgh University of Puerto Rico University of Saskatchewan University of Southern California University of Tennessee University of the Pacific University of Toronto University of Utah School of Dentistry University of Washington University of Western Ontario UT Health Science Center at Houston UT Health Science Center at San Antonio Vanderbilt University Virginia Commonwealth University Washington University - St. Louis West Virginia University Western University of Health Sciences * Year of Graduation *
I am currently... In Public HealthIn Dental SchoolCo-Owner of a PracticeAn Associate in a Practice
Looking to relocateAssociate in a ClinicIn a residency programSole Owner of a Practice
In Military
*
Separation Date
I am interested in... Associateship (Placement)Earning Equity in a PracticeMerger
Partnership / Buy-InPurchase

Desired Annual Income How did you hear about AFTCO? Cold Call Journal Ad Mailing Search Engine Tradeshow Website Other Website Word of Mouth Referral Voicemail Tyson Steele Email Previous Client Study Club Other *
Additional Comments

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