(410) 742-0108
1006 N. Salisbury Blvd, Salisbury, MD 21801
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New Customer Registration
Doctor & Practice Information
Who referred you to DJDL?
Your Name: Dr.
(Required)
First
Last
License Number
Dental Practice Name:
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone Number:
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Email:
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Billing Contact Information
We send monthly statements by email and follow up by phone when needed for billing purposes. Please provide the following information for the person in your office in charge of finances. This may be an accountant, office manager, office assistant, etc.
Name
(Required)
First
Last
Email (to receive statements):
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Phone:
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Products & Services
AI Implant Crowns
Emax Crowns
Emax Veneers
Implant Overdenture
Layered Zirconia Esthetic
PFM Crowns
Zirconia Crowns/Solid
Acrylic Partials
Bite Blocks
Cast Partials
Custom Trays
Essix Retainer
Flexible Partials and nesbits
Flippers
High Impact Dentures
Immediate denture
Implant Cases
Ortho Retainers
Same day denture from bite block
Implants
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