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530 Chauvet Drive
Pittsburgh, PA 15275
Tel: (412) 876-8003
E-Mail: info@terrificteethpd.com
Responsible Party Information
Parent/Guardian 1
Date Of Birth
Contact Information
SSN
Address
City
State
Zip Code
Employer
Occupation
Parent/Guardian 2
Date Of Birth
Contact Information
SSN
Address
City
State
Zip Code
Employer
Occupation
Do you have Dental Insurance?
*Please include Dental Insurance only, not Medical.
*If Delta Dental, please specify through which State (ex: Delta Dental of MA)
Primary Dental Insurance
Subscriber
ID Number
Group Number
Secondary Dental Insurance
Subscriber
ID Number
Group Number
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