DentaMile connect Account Information

Before you can begin using DentaMile connect, we must create your DentaMile connect account. Please complete the form and click submit to complete the request.

Organization Information

Name *

Email *

Phone *

Address Line 1 *

Address Line 2

City *

Zip Code *

Country *United States of AmericaCanada

Lead Contact Information

The designated lead contact will receive information and correspondence from the DentaMile network.

First Name *

Last Name *

Email *

Organization Type *

• Laboratory
• Surgery

DentaMile connect Licenses *

• Creator
• Creator Plus
• Designer
• Producer

User #1

First Name *

Last Name *

Title *

Username *

Email *

Account Role *

• Admin

User #2 (optional)

First Name

Last Name

Title

Username

Email

Account Role

• Technician
• Dentist

User #3 (optional)

First Name

Last Name

Title

Username

Email

Account Role

• Technician
• Dentist

For Internal Use Only

Sales Team Email

Submit