HPSM Dental Application Form

Thank you for your interest in joining HPSM’s network as a dental provider for our Medi-Cal members. To apply, fill out and submit the online application form below.

Each provider who will render services for the agency/organization, including associates and trainees, must fill out a separate application.

  • The form takes about 10-15 minutes to complete: it automatically times out after 30 minutes of non-activity and cannot be saved 
  • After you submit your application, an HPSM Provider Services Credentialing Specialist will review your qualifications to ensure they meet HPSM’s standards for network membership
  • You should hear from HPSM about the status of your application within two business days
  • If you have any questions, please email dental@hpsm.org

Dental Provider Application Form

  • 1 Info
  • 2 Specialties
  • 3 Group
  • 4 Site
  • 5 Submit

Your Information


Your Supervisor

Required for specific provider types such as, NP, PA, Midwife, AMFT, RDH, etc. If not applicable, continue to the next section.

Your Specialties

Type of dentist:

122300000X - Dentist 1223G0001X - General Practice 1223D0001X - Dental Public Health 1223D0004X - Dentist Anesthesiologist 1223X0008X - Oral & Maxillofacial Radiology 1223S0112X - Oral & Maxillofacial Surgery 1223E0200X - Endodontics 1223P0106X - Oral & Maxillofacial Pathology 1223X0400X - Orthodontics & Dentofacial Orthopedics

1223P0221X - Pediatric Dentistry 1223P0300X - Periodontics 1223P0700X - Prosthodontics122400000X - Denturist 124Q00000X - Dental Hygienist 125J00000X - Dental Therapist 125K00000X - Advanced Practice Dental Therapist 125Q00000X - Oral Medicinist 126800000X - Dental Assistant


Age groups served:

Medi-Cal enrolled:

Board certification:


Group Information

Please complete this section if you are applying as part of a clinic.


Site Information

Site facility type:

Site handicapped accessible:

Onsite telecommunications device for the deaf (TDD):

Onsite laboratory services:

Onsite X-ray services:


Review and Submit

Please review the information you provided for accuracy and make any corrections needed. Then click the Submit Application button to complete your application. An HPSM Provider Services Credentialing Specialist will contact you after reviewing your application.

Review information