Dental Services

Primary Subscriber’s Information

Agent Number: 003463

Please provide us with your name, mailing address, date of birth, and social security number:


If paying by check please skip the credit card information, select your annual payment choice then print the whole enrollment form, filled out. Mail it along with appropriate payment to:

California Dental

P.O. Box 7937, Stockton, CA. 95267

If paying by credit card please fill in the following information:

Discover

Please select annual payment choice:

Single

Member & 1 dependent

Family

$150.00

Please enter the name and office number of the dentist you are considering using. This information can be found on the ‘find a dentist’ tab. Keep in mind you can visit any of the dentists in our extensive network.

Dental Office Name & Number:

I agree

When finished filling out all the appropriate information please click the submit button

Spouse Information

Dependant Children

Payment Information

Dental Office