Total Dental Administrators, Inc.
2111 E Highland Avenue, Suite 250
Phoenix, Arizona 85015
(602) 266-1995 or (888) 422-1995
www.TDADental.co
Valley City State University employees: Total Dental Administrators, Inc. (TDA) is pleased to offer the Elite Choice
dental benefit plan option to you during the Plan Year 2016.
The Elite Choice Plan is designed to encourage you to visit the dentist and help ensure your basic dental needs are met in a
timely and cost effective manner. Our plan offers you the option of receiving your dental care from any dentist you choose
(Out of Network) or from any Participating Plan Dentist (In-Network). However, if you elect to receive your dental care
from an In-Network dentist, you’re out of pocket costs will be less.
Highlights of the TDA Elite Choice Group Dental Plan are as follows:
TDA ELITE CHOICE GROUP DENTAL PLAN
Calendar Year Deductible
IN-NETWORK
OUT-OF-NETWORK
None
$50 per person / $150 per family
Class 1: Preventive & Diagnostic
Copays
Class 2: Restorative / Fillings
Copays
Class 3: Crowns, Endo, Perio, Prosthodontics, Oral Surgery
Copay
Balance Billing Allowed
Waiting Periods
Annual Benefit Maximum
Deductible is Not Applicable
Plan Pays Allowance to Provider
Enrollee may be Balance Billed
Deductible is Applicable
Plan Pays Allowance to Provider
Enrollee may be Balance Billed
Deductible is Applicable
Plan Pays Allowance to Provider
Enrollee may be Balance Billed
No
Yes
None
Six (6) months for Class 3 Services
Total Maximum of $2,000 per Covered Person
(For a complete list of covered services and limitations/exclusions, please refer to the Dental Benefit Plan Summary)
2016 Monthly Rates
$28.56
$54.40
$90.94
Employee Only
Employee + 1 Dependent
Employee + 2 or More Dependents
You are eligible to enroll on the TDA Elite Choice Dental plan if you are an employee of:




The State of North Dakota
North Dakota State University
Minot State University
Dickinson University




North Dakota State College of Science
University of North Dakota
Valley City State University
Bank of ND Garrison Diversion District




Mayville State University
Williston Stat College
Bismarck State College
District Health Units
Attached are the TDA Elite Choice Dental Plan Summary of Benefits Brochure, Enrollment form, Provider Directory
and a Provider nomination form. You may also search for contracted providers on TDA’s Web site at www.tdadental.com
If you have any questions, please feel free to call or e-mail TDA’s representatives for assistance.
Ron Holden (701) 721-3716 [email protected] or Chris Jehle (602) 320-3261 [email protected]
Thank you and we look forward to serving you in 2016.
Elite Choice
Group Dental Plan
The State of North Dakota
Employees of the State of North Dakota, the University System, District Health Units and Garrison
Diversion Conservancy District are eligible to participate in this plan
ProviDent
2111 East Highland Avenue, Suite 250
Phoenix, Arizona 85016
1-16-R1
888-422-1995 • 602-266-1995
602-266-1948 (FAX)
Plan Pays to Dentist,
Patient responsible for
difference
Out-of-Network
Description
Patient Copay
Code
In-Network
ELITE CHOICE GROUP
DENTAL PLAN
CLASS I DIAGNOSTIC
Welcome to the ELITE CHOICE GROUP DENTAL
PLAN available exclusively from Total Dental
Administrators.
The ELITE CHOICE DENTAL PLAN offers you the
option of receiving your dental care from any dentist you
choose (Out-Of-Network) or from any Participating Plan
Dentist (In-Network); and you don't need to make that
decision until you need dental care! However, should you
elect to receive your dental care from an In-Network
dentist, your out of pocket costs will be less.
The following is an outline of your dental coverage. For
a complete listing of procedures please refer to the
employee booklet/certificate you will receive after
enrollment. Services not listed are available on a fee for
service basis, no discount applies.
Elite Plan Advantages
•
•
No In-Network Deductibles
$2,000 Annual Maximum
•
No In-Network Waiting Period
(6 Month Waiting Period for Major Services Out-Of-Network)
Utilizing An In-Network Dentist
There are no deductibles for dental services provided by
participating In-Network dentists. Co-pays in the column titled
“In-Network” apply to services performed by participating InNetwork dentists only. The member is responsible for the
amount listed under the In-Network Patient Co-pay.
Utilizing An Out-Of-Network Dentist
There are no deductibles for Diagnostic or Preventive (Class I)
services. A $50.00 per person and $150.00 per family annual
deductible will be applied to all dental services not listed in the
Diagnostic and Preventive (Class I) categories. Members must
meet a 6-month waiting period for all Major (Class III) services.
The fees listed in the column titled “Out-Of-Network” are what
the plan covers toward those services. The member is
responsible for the difference between the amount paid by the
plan, and the amount your dentist charges. The member is
therefore responsible for any balanced-billed amount.
1-16-R1
D0120
D0140
D0150
D0180
D0210
D0220
D0230
D0272
D0274
D0277
D0330
Periodic Oral Evaluation
Limited Oral Evaluation
Comprehensive Oral Evaluation
Comprehensive Perio Oral Eval
Intraoral-Complete Incl Bitewings
Intraoral - Periapical First Film
Intraoral-Periapical- Ea Addl Film
Bitewings- 2 Films
Bitewings- 4 Films
Vertical Bitewings- 7-8 Films
Panoramic Film
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$32.00
$47.00
$53.00
$51.00
$85.00
$21.00
$16.00
$35.00
$44.00
$65.00
$80.00
CLASS I PREVENTIVE
D1110
D1120
D1206
D1208
D1351
D1510
D1515
Prophylaxis-Adult
Prophylaxis-Child
Topical application of fluoride varnish
Topical application of fluoride
Sealant- per tooth
Space maintainer-fixed-unilateral
Space maintainer - fixed bilateral
$15.00
$10.00
No Charge
No Charge
$15.00
No Charge
No Charge
$48.00
$33.00
$43.00
$25.00
$17.00
$198.00
$278.00
CLASS II RESTORATIVE
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
Amalgam-1 surface
Amalgam- 2 surfaces
Amalgam-3 surfaces
Amalgam-4 or more surfs
Resin-1 surface, anterior
Resin-2 surfaces, anterior
Resin-3 surfaces, anterior
Res-4 or more surf-invl inc angle ant.
Resin-based composite crown,
anterior
Resin-based composite - 1 surf, post
Resin-based composite - 2 surf, post
Resin-based composite-3 surf post
Resin-based composite-4 or more
surf, post
$55.00
$55.00
$65.00
$65.00
$65.00
$70.00
$75.00
$95.00
$35.00
$54.00
$75.00
$97.00
$47.00
$69.00
$85.00
$112.00
$100.00
$70.00
$85.00
$95.00
$110.00
$45.00
$85.00
$97.00
$150.00
$137.00
CLASS III RESTORATIVE
D2510
D2520
D2530
D2740
D2750
D2751
D2752
D2790
D2930
D2932
D2950
Inlay-metallic-1 surface
Inlay metallic -2 surfaces
Inlay-metallic 3 or more surf
Crown-porcelain ceramic substrate
Crown-porcelain-high noble metal
Crown-porcelain-predom base metalic
Crown-porcelain fused-noble metal
Crown-full cast high noble metal
Crown - Prefabricated Stainless Steel Primary tooth
Prefabricated resin crown
Core build-up, including any pins
$350.00
$350.00
$400.00
$605.00
$605.00
$585.00
$595.00
$605.00
$219.00
$245.00
$302.00
$207.00
$192.00
$178.00
$175.00
$194.00
$140.00
$140.00
$130.00
$58.00
$135.00
$68.00
CLASS III RESTORATIVE
CONTINUED
D2951
D2952
D2954
D2980
Pin ret/tooth, in add-restoration
Cast post and core in add to crown
Prefab post/core in add to crown
Crown repair, by report
$25.00
$155.00
$155.00
$75.00
D3425
D3430
D3450
Pulp cap-direct (exc final rest)
Pulp cap-indir (exc final rest)
Thera pulpotomy (exc final rest)
Root canal-anterior (excl finl rest)
Root can-bicuspid (excl fnl rest)
Root canal-molar (excl final rest)
Retreat Prev Root Canal - Anterior
Retreat Prev Root Canal - Bicuspid
Retreat Prev Root Canal - Molar
Apicoectomy/periradicular surg-antr
Apicoectomy/Periradicular surg-Bicusp1st Rt
Apicoectomy/Periradicular surg-Molar
1st Rt
Retrograde filling-per root
Root amputatuion-per root
$12.00
$106.00
$84.00
$34.00
$30.00
$25.00
$75.00
$295.00
$360.00
$450.00
$360.00
$410.00
$510.00
$300.00
$15.00
$14.00
$32.00
$156.00
$200.00
$270.00
$280.00
$325.00
$350.00
$236.00
$290.00
$273.00
$400.00
$95.00
$185.00
$276.00
$82.00
$131.00
D4211
D4240
D4241
D4341
D4342
D4355
D4910
Gingivectomy or gingivoplasty-quad 4
or more teeth
Gingivectomy or gingivoplasy-tooth 1 to
3 teeth
Ging flap proc inc root plng/quad 4 or
more teeth
Ging flap proc inc root plng/tooth 1 to 3
teeth
Perio scaling & root plng-quad 4 or
more teeth
Perio scaling & root plng-tooth 1 to 3
teeth
Full mouth debride-enable eval & dx
Perio maint proc following act ther
$150.00
$255.00
$80.00
$62.00
$225.00
$278.00
$95.00
$169.00
$115.00
$71.00
$55.00
$65.00
$55.00
$44.00
$42.00
$43.00
CLASS III REMOVABLE
PROSTHODONTICS
D5110
D5120
D5130
D5140
D5211
D5212
D5510
D5520
D5610
D5630
D5640
D5650
D5660
D5850
D5851
D6210
1-16-R1
Complete denture maxillary
Complete denture-mandibular
Immediate denture-maxillary
Immediate denture-mandibular
Maxillary part denture-resin base
Mandibular part denture-resin base
Repair broken comp denture base
Replace miss/brkn teeth-comp dent
Repair resin denture base
Repair or repl brkn clasp, pd
Replace brkn teeth/ tooth, pd
Add tooth to existing pd
Add clasp to existing pd
Tissue conditioning, maxillary
Tissue conditioning, mandibular
Pontic-cast high noble metal
D6010
D6056
D6057
D6058
D6059
D6060
D6061
D6062
D6063
D6065
Plan Pays to Dentist,
Patient responsible for
difference
Out-of-Network
Patient Copay
Surgical placement of implant:
endosteel implant.
$1650.00
Prefabricated abutment – includes
placement.
$295.00
Custom abutment – includes placement
$475.00
Abutment supported porcelain/ceramic
crown.
$895.00
Abutment supported porcelain fused to
metal crown (high noble metal).
$885.00
Abutment supported porcelain fused to
metal crown (predominantly base metal) $775.00
Abutment supported porcelain fused to
metal crown (noble metal)
$775.00
Abutment supported cast metal crown
(high noble metal).
$775.00
Abutment supported cast metal crown
(predominantly base metal)
$775.00
Implant supported porcelain/ceramic
crown.
$795.00
$150.00
$135.00
$119.00
$214.00
$209.00
$284.00
$305.00
$301.00
$165.00
$346.00
CLASS III ORAL SURGERY
CLASS III PERIODONTICS
D4210
Description
CLASS III IMPLANTS
CLASS III ENDODONTICS
D3110
D3120
D3220
D3310
D3320
D3330
D3346
D3347
D3348
D3410
D3421
Code
In-Network
Plan Pays to Dentist,
Patient responsible for
difference
Out-of-Network
Patient Copay
Description
In-Network
Code
$895.00
$895.00
$925.00
$925.00
$585.00
$585.00
$65.00
$65.00
$60.00
$100.00
$60.00
$100.00
$100.00
$60.00
$60.00
$500.00
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7510
D7960
$35.00
$34.00
$55.00
$110.00
$125.00
$165.00
$195.00
$44.00
$57.00
$65.00
$81.00
$93.00
$255.00
$110.00
$75.00
$190.00
$44.00
$65.00
$113.00
$65.00
$40.00
$28.00
$165.00
$140.00
$50.00
$61.00
$165.00
$140.00
$50.00
$61.00
OTHER SERVICES
D9110
D9220
D9221
D9241
$236.00
$236.00
$274.00
$274.00
$310.00
$310.00
$48.00
$34.00
$67.00
$60.00
$43.00
$51.00
$74.00
$39.00
$39.00
$194.00
Extraction, coronal remnants-deciduous
tooth
Extraction, erupted tooth or esposed
root
Surg rem erup tooth req flap/bone
Remov of impacted tooth-soft tis
Remov of impacted tooth-par bony
Remov of impacted tooth-comp bony
Remov of impacted tooth-comp bony,
complicated
Surg rem of residual tooth roots
I&d abscess intraoral-soft tissue
Frenulectomy-frenectomy/frenotomy
D9242
Palliative (er) tx-dent pain-minor
Deep Sedation/General Anesthesia –
first 30 minutes
Deep Sedation/General Anesthesia each Add'l 15 minutes
IV Conscious Sedation, first 30
minutes
IV Conscious Sedation, each
additional 15 minutes
Class III Services are subject to a 6-month waiting period
when provided by an Out-of-Network dentist.
Principal Exclusions & Limitations
Covered Expenses Will Not Include and No Benefits Will Be Payable:
1.
2.
3.
In the first twelve months that a person is insured if the person is a
Late Entrant; except for exams, cleanings and fluoride application.
The benefits are limited to procedures numbered 0120, 0140, 0150,
0180, 1110, 1120, 1206 and 1208.
For any treatment which is for cosmetic purposes, or to correct
congenital malformations, other than medically necessary treatment
of congenital cleft in the lip or palate, or both.
To replace any prosthetic appliance, crown, inlay or onlay
restoration, or fixed bridge within five years of the date of the last
placement of these items. But if a replacement is required because of
an accidental bodily injury sustained while the Insured is covered
under this section, it will be a Covered Expense.
16. For charges for which the Insured is not liable or which would not
have been made had no insurance been in force.
17. For services which are not recommended by a dentist or which are
not required for necessary care and treatment.
18. Because of ware or any act of war, declared or not.
19. To an Insured if payment is not legal where the Insured is living
when expenses are incurred.
20. Any services related to: equilibration; bite registration or bit
analysis.
21. Crowns for the purpose of periodontal splinting.
4.
5.
6.
For initial placement of any prosthetic appliance or fixed bridge
unless such placement is needed because of the extraction of one or
more natural teeth while the Insured is covered under this section.
But the extraction of a third molar (wisdom tooth) will not qualify
under the above. Any such appliance or fixed bridge must include
the replacement of the extracted tooth or teeth.
For any procedure begun before the Insured was covered under this
section.
For any procedure begun after the Insured’s insurance under this
section terminates; or for any prosthetic dental appliances installed or
delivered more than 90 days after the Insured’s insurance under this
section terminates.
7.
To replace lost or stolen appliances.
8.
For appliances, restorations, or procedures to:
a. alter vertical dimensions;
b. restore or maintain occlusion’
c. splint or replace tooth structure lost as a result of abrasion or
attrition; or
d. treat disturbances of the temporomandibular joint.
9.
22. Charges for: any implants; precision or semi-precision attachments
and any endodontic treatment associated with it; other customized
attachments, unless specifically listed in this booklet.
23. For endodontic treatment of the same tooth within a three (3) year
period.
24. For root canal retreatment when it has not been demonstrated that
unusual morphological or pathological conditions exist and when
performed by a non-endodontic specialist.
25. For more than one filling for each tooth surface in a 24 month period.
26. For non-surgical periodontal treatment more than once in two (2)
year period.
27. For surgical periodontal treatment more than once in a three (3) year
period.
28. For crown build-ups when less than three (3) of the five (5) tooth
surfaces are destroyed.
29. For crown build-ups (pin, bonded, or post and core) more than once
in a five (5) year period.
For any procedure which is not shown on the List of Dental
Procedures.
Managed by
The image part with relationship ID rId18 was not found in the file.
10. For education or training in, and supplies used for, dietary or
nutritional counseling, personal oral hygiene or dental plaque control.
11. For the completion of claim forms.
12. For sealants which are:
a. not applied to a permanent molar;
b. applied after attaining age 17;
c. applied to a molar more than once.
13. Gingival flap procedure, including root planning (procedure numbers
4240, 4241, 4340 and 4341) unless the presence of periodontal
disease is confirmed by both x-rays and pocket depth summaries of
each tooth involved.
14. Because of an injury arising out of, or in the course of, work for wage
or profit.
15. By an Insured because of a sickness, injury or condition for which he
or she is eligible for benefits under Worker’s Compensation or
similar laws.
1-16-R1
Highland
Avenue,
21112111
EastEast
Highland
Avenue,
Ste. 250
Suite
250
Phoenix, Arizona 85016
Phoenix, Arizona 85016
888-422-1995 • 602-266-1995
888-422-1995
• 602-266-1995
602-266-1948
(FAX)
602-266-1948 (FAX)
www.tdadental.com
Rated A+ (Superior) by A.M. Best and
Rated A (Excellent) by Weiss Rating, Inc.
PPO PROVIDER DIRECTORY
Prairie Rose Family Dentists
121 East Front Avenue
Sidney Schmidt, DDS
Prairie Rose Dental
900 East Calgary Avenue
Chris Spies, DDS
Prairie Rose Dental
900 East Calgary Avenue
Chris Spies, DDS
Prairie Rose Family Dentists
121 East Front Avenue
Ashley Wangler, DDS
The Dental Suite PC
3000 N 14th St.
Nicholas Wangler, DDS
The Dental Suite PC
3000 N 14th St.
Thomas York, DDS
York Thomas
1102 S. Washington
GENERAL DENTISTS
BISMARCK
Kevin Bjork, DDS
(701) 222-1009
Bjork Dental
1929 N. Washington St, Suite 00
Casey Carlson, DDS
(701) 223-1194
Prairie Rose Dental
900 East Calgary Avenue
Casey Carlson, DDS
(701) 223-1194
Prairie Rose Family Dentists
121 East Front Avenue
Anthony Frank, DDS
(701) 258-5220
A Lifetime of Smiles
1004 S. 7th Street
Kevin Gilchrist , DDS
(701) 222-1213
Dr. Kevin Gilchrist
1929 N Washington St.
Richard Hieb, DDS
(701) 223-1194
Prairie Rose Dental
900 East Calgary Avenue
Richard Hieb, DDS
(701) 223-1194
Prairie Rose Family Dentists
121 East Front Avenue
Derik Hoener, DDS
(701) 258-5220
A Lifetime of Smiles
1004 S. 7th Street
Leslie Hollevoet, DDS
(701) 223-1194
Prairie Rose Family Dentists
121 East Front Avenue
Leslie Hollevoet, DDS
(701) 223-1194
Prairie Rose Dental
900 East Calgary Avenue
Bradley King, DDS
(701) 223-1194
Prairie Rose Dental
900 East Calgary Avenue
Bradley King, DDS
(701) 223-1194
Prairie Rose Family Dentists
121 East Front Avenue
Dean Knudsen, DDS
(701) 258-3308
Knudsen Dean
714 South 2nd Street
Steve Midstokke, DDS
(701) 255-0475
Midstokke Family Dentistry
2940 N. 19th Street #3
Kevin Munns, DDS
(701) 223-1194
Prairie Rose Dental
900 East Calgary Avenue
Kevin Munns, DDS
(701) 223-1194
Prairie Rose Family Dentists
121 East Front Avenue
Riley Parker, DMD
(701) 204-7232
Parker Dental Clinic LLC
4501 Coleman St #107
William Quinn, DDS
(701) 223-1194
Prairie Rose Family Dentists
121 East Front Avenue
William Quinn, DDS
(701) 223-1194
Prairie Rose Dental
900 East Calgary Avenue
Andrew Schmid , DDS
(701) 222-1009
Bjork Dental
1929 N. Washington St, Suite 00
Sidney Schmidt, DDS
(701) 223-1194
(701) 223-1194
(701) 223-1194
(701) 223-1194
(701) 255-0469
(701) 255-0469
(701) 223-4915
BOWMAN
Patrick Kelly, DDS
Kelly Patrick
608 Highway 12 W.
(701) 523-3255
COOPERSTOWN
Arlo Neumiller, DDS
Agassiz Dental Associates
1200 Roberts Avenue NE
(701) 797-2641
CROSBY
Edward Maisey, DDS
Edward Maisey DDS
112 1st St. NW
Willam Maisey, DDS
William Maisey, DDS
112 1st St. NW
(701) 965-4362
(701) 965-4362
DRAYTON
Andrew Duncklee, DDS
Duncklee Andrew
110 N. Main
(701) 454-6218
ENDERLIN
Duane Krivarchka, DDS
Krivarchka Duane
213 4th Ave.
(701) 437-2676
FARGO
Tanya Bonicelli, DDS
Dr B Dentistry PC
1701 38th Street SW
Joshua Breding, DDS
Family Healthcare Center
301 NP Avenue
Joanna Brekhus, DDS
Family Healthcare Center
301 NP Avenue
Jonathan Bultema, DDS
Family Healthcare Center
301 NP Avenue
James Colbert, DDS
Fargo Family Dentistry
3210 18TH ST S
Jonathan Dahl, DDS
(701) 282-4044
(701) 271-3349
(701) 271-3349
(701) 271-3349
(701) 237-6008
(701) 237-5616
** Roster Only
***** Closed to New DHMO Patients
Page 1
October 16, 2015
PPO PROVIDER DIRECTORY
Jonathan P Dahl DDS DS PC
1324 23rd St S
James F Johnson, DDS
Johnson DDS, James F
825 28th Street SW
Robert Mack, DDS
Jonathan P Dahl DDS DS PC
1324 23rd St S
Marie Moeckel, DDS
Moeckel Family Dentistry
1815 University Dr. S #3
Lynne M Olson Rommesmo, DDS
Lynn M Olson Rommesmo
1115 19th Avenue N
James Podrebarac, DDS
Family Healthcare Center
301 NP Avenue
Lindsay Rogers, DDS
Family Healthcare Center
301 NP Avenue
Courtney Rud, DDS
Family Healthcare Center
301 NP Avenue
Mark Runyan , DDS
North Creek Dental
100 South 4th #312
Svetlana Sampson, DDS
About Smiles Dental LLC
4575 23rd Ave S
Mark Schaffer, DDS
North Creek Dental
100 South 4th #312
Samuel Sticka, DDS
Family Healthcare Center
301 NP Avenue
Andrea Wilson, DMD
Family Healthcare Center
301 NP Avenue
1165 B S. Columbia Rd.
Dan Schefter, DDS
Schefter DDS, Dan
3001 32nd Avenue South
Duc V Tran, DDS
D Tran DDS PC
600 DeMers Avenue
(701) 237-4297
(701) 237-5616
(701) 293-0751
Marlin Meharry, DDS
Marlin G Meharry
317 East Brewster Street
(701) 293-8625
(701) 324-4861
LISBON
Duane Krivarchka, DDS
Krivarchka Duane
11 11th Avenue West
Ryan Nelson, DDS
Lisbon Smiles
420 Main St PO 1078
(701) 271-3349
(701) 271-3349
(701) 271-3349
(701) 683-4455
(701) 683-7695
MANDAN
Leah Brady, DDS
Ideal Image Dentistry
1008 East Main Street
Nicole Duckwitz, DDS
Dental Associates
204 3rd Avenue NM
John Grunseth, DDS
Dental Associates
204 3rd Avenue NM
Michael Maier, DDS
Dental Associates
204 3rd Avenue NM
Anthony Malaktaris, DDS
Dental Associates
204 3rd Avenue NM
(701) 232-2409
(701) 356-4077
(701) 232-2409
(701) 271-3349
(701) 271-3349
(701) 667-1933
(701) 663-7545
(701) 663-7545
(701) 663-7545
(701) 663-7545
MAYVILLE
Robert Lauff, DDS
Goose River Dental
37 ½ E. Main Street
(701) 352-2450
(701) 352-0730
Stanley Hirst, DDS
Stanley Hirst
1839 S Broadway
Bethany Jensen, DDS
Stanley Hirst
1839 S Broadway
Larry Scouton, DDS
Scouton Larry
315 Main St. S.
(701) 358-2013
(701) 775-7441
(701) 788-4064
MINOT
(701) 352-2450
GRAND FORKS
John Baden, DDS
John J Baden, DDS
2512 South Washington
Steven Erlandson, DDS
Steven Erlandson
2401 S. Washington St. #D
Brian Nord, DDS
Nord Dentistry
2720 17TH AVE S
Brian Parr, DDS
Brian C. Parr, DDS
(701) 775-7611
HARVEY
GRAFTON
Boone Brewer, DDS
Boone T Brewer DDS PLLC
17 East 7th Street
Neil Daby, DMD
Daby Neil
15 E. 7th St.
James Duerre, DDS
Duerre James
17 E. 7th St.
Joseph Kern, DDS
Kern Family Dentistry
21 West 5th Street
(701) 775-7005
(701) 839-1299
(701) 839-1299
(701) 838-3051
NEW TOWN
J.W. Hamilton, DDS
J.W. Hamilton
Main Street
(701) 772-6581
(701) 627-4766
TIOGA
David Carlson, DDS
David Carlson DDS
111 Main
(701) 772-6922
(701) 772-3544
(701) 664-2582
TURTLE LAKE
Wilton Kuehn, DDS
(701) 448-9111
** Roster Only
***** Closed to New DHMO Patients
Page 2
October 16, 2015
PPO PROVIDER DIRECTORY
Kuehn Wilton
416 Kundert St
JAMESTOWN
Michael Noffze, DDS
(701) 237-4113
Oral Maxillofacial Associates
920 10th St SE
VALLEY CITY
Lynn Odne, DDS
Odne Lynne
915 2nd Street SW
(701) 524-2814
WEST FARGO
Troy Petersen, DMD
Valley Oral & Facial Surgery
3187 Bluestem Dr, Ste. 4
Rudy Schneider, DMD
Valley Oral & Facial Surgery
3187 Bluestem Dr, Ste. 4
Marcus Tanabe, DDS
Valley Oral & Facial Surgery
3187 Bluestem Dr, Ste. 4
WAHPETON
Susan Swanson, DDS
(701) 671-2333
N. D. College-Hygiene Services
800 6th St. N.
Mark Wasemiller, DDS
(701) 642-4866
Wasemiller Mark
275 11th St. S.
(701) 235-7379
(701) 235-7379
(701) 235-7379
WATTFORD CITY
Edward Maisey, DDS
Edward Maisey DDS
109 5th St. SW
(701) 842-4474
PEDODONTISTS
BISMARCK
Travis Giese, DDS
Prairie Rose Family Dentists
121 East Front Avenue
Travis Giese, DDS
Prairie Rose Dental
900 East Calgary Avenue
WILLISTON
Scott Ellis, DDS
Ellis Scott
501 Main Street
John Hamilton, DDS
Hamilton John
2204 2nd Avenue West
Edward Maisey, DDS
Edward Maisey DDS
708 Main
Willam Maisey, DDS
Edward Maisey DDS
708 Main
(701) 774-1941
(701) 774-8822
(701) 774-1879
PROSTHODONTISTS
Loye Ashton, DDS
Powers Lake Dental Clinic
120 Main St.
(701) 774-1879
(701) 464-5646
WILLISTON
Loye Ashton, DDS
Ashton Loye
120 Main Street
FARGO
(701) 232-1956
(701) 572-9461
GENERAL DENTISTS
(701) 232-1956
BARNESVILLE
Jonathan Dahl, DDS
Jonathan Dahl, DDS, PC
102 Front Street
Stacy Gould Seaborn, DDS
Jonathan Dahl, DDS, PC
102 Front Street
Robert Mack, DDS
Jonathan Dahl, DDS, PC
102 Front Street
GRAND FORKS
Kelli Swenson, DDS
(701) 757-9777
Cook & Swenson Endodontics
3425 S Washington St, Ste B
ORAL SURGEONS
FARGO
Michael Noffze, DDS
(701) 232-9565
Oral Maxillofacial Associates
300 Main Ave #201
(701) 772-7379
(218) 354-2289
(218) 354-2289
(218) 354-2289
CHOKIO
Timothy Carlson, DDS
Chokio Dental
118 Main St.
GRAND FORKS
Troy Petersen, DMD
Valley Oral & Facial Surgery
1165 South Columbia Road
Marcus Tanabe, DDS
Valley Oral & Facial Surgery
1165 South Columbia Road
(701) 223-1194
POWERS LAKE
ENDODONTISTS
Jerry Cook, DMD
Cook Endodontics
Available 11-01-2010
Michael D Peterson, DMD
Cook Endodontics
Available 11-01-2010
(701) 223-1194
(320) 324-7545
DETROIT LAKES
Thomas Fritz, DDS
Dental Associates
1136 Washington Ave.
Elizabeth McCauley, DDS
Dental Associates
1136 Washington Ave.
(701) 772-7379
(218) 847-2624
(218) 847-2624
** Roster Only
***** Closed to New DHMO Patients
Page 3
October 16, 2015
PPO PROVIDER DIRECTORY
Dr. Riewer, DDS
Dr. Riewer
1137 Jackson Ave.
Dr. Steinmetz, DDS
Dr. Steinmetz
1137 Jackson Ave.
Carolyn Zunich, DDS
Dental Associates
1136 Washington Ave.
(218) 847-9214
WHEATON
Michael Marchetti, DDS
Marchetti Michael
1511 Broadway
(218) 847-9214
ORAL SURGEONS
ALEXANDRIA
Robert Keck, DDS
(320) 763-5117
Centrasota Oral & Maxillofacial Surgeons
510 22nd Ave. E. Ste. 103
Harold Machesky, DDS
(320) 763-5117
Centrasota Oral & Maxillofacial Surgeons
510 22nd Ave. E. Ste. 103
Gustavo Pena-Velasco, DDS
(320) 763-5117
Centrasota Oral & Maxillofacial Surgeons
510 22nd Ave. E. Ste. 103
Donald Primley, DDS
(320) 763-5117
Centrasota Oral & Maxillofacial Surgeons
510 22nd Ave. E. Ste. 103
Eric Stine, DDS
(320) 763-5117
Centrasota Oral & Maxillofacial Surgeons
510 22nd Ave. E. Ste. 103
Roderick VanSurksum, DDS
(320) 763-5117
Centrasota Oral & Maxillofacial Surgeons
510 22nd Ave. E. Ste. 103
(218) 583-2029
MENAHGA CITY
Charles Restemayer, DDS
Restemayer Charles
16 Birch Ave.
(218) 564-5192
MOORHEAD
Joanna Brekhus, DDS
Family Healthcare Center
715 North 11th Street #106B
William Savage, DDS
Family Healthcare Center
715 North 11th Street #106B
Andrea Wilson, DMD
Family Healthcare Center
715 North 11th Street #106B
(218) 299-7830
(218) 299-7830
(218) 299-7830
SAINT CLOUD
Harold Machesky, DDS
Machesky Harold
3950 Vetrans Drive #100
NEW YORK MILLS
Rachel Grieger, DDS
Grieger Rachel
206 Walker Ave. N.
(320) 563-4641
(218) 847-2624
HENNING
Michael Berglund, DDS
MICHAEL BERGLUND DDS
404 Douglas Ave.
124 Colfax Ave. SW
(218) 385-3130
(320) 252-3611
PARK RAPIDS
Guy Reich, DDS
Reich Guy
314 Pleasant Ave. S.
Christina Robin, DDS
Northwoods Dental Clinic
120 Main Ave. N.
(218) 732-4466
(218) 732-1414
PERHAM
Michael Hamann, DDS
Hamann Michael
200 1st Ave. S.
(218) 346-4775
SALOL
Bruce Falk, DDS
Falk Dental
34683 CO Rd. 133
(218) 463-1828
WADENA
Ryan Anderson, DDS
Woodland Dental Inc.
206 First St. SE
Wayne Howard, DDS
Howard Wayne
122 Colfax Avenue SW
James Matthiae, DDS
James Matthiae, DDS
206 1st St. SE
Christopher OKane, DDS
Christopher O'Kane DDS
(218) 631-4431
(218) 631-4525
(218) 631-1487
(218) 631-2515
** Roster Only
***** Closed to New DHMO Patients
Page 4
October 16, 2015
GROUP DENTAL ENROLLMENT FORM
New Employee
Add Coverage
Add/Delete Dependent
Decline Coverage
Cancel Coverage
Address/Name Change
Loss of Other Coverage
Transfer From DHMO
Transfer From PPO
COBRA Enrollment
Name of Employer: (Use Name from Group Billing Notice or Master Application)
Group Number:
Class:
Valley City State University
Plan Types:
Elite Choice
Social Security Number
Your Name (Last),
Effective Date
Month / Day / Year
(First),
Date Employed Fulltime
Month / Day / Year
Date of Birth
Month / Day / Year
(MI)
Home Phone Number:
Male:
Female:
Employee Only
Employee + 1
Employee + Family
.
Complete for Dependent Coverage:
(Last),
Work Phone Number:
Do you have any other Dental coverage? If so, Carrier
(First),
(MI)
Sex:
C
H
I
L
D
R
E
N
Sex:
Coverage Requested:
Home Address:
Spouse Name:
Hours Worked Per Week
Date of Birth:
Do any of your dependents have any other
dental
If so, Name of Carrier:
coverage?
/
/
Yes No
1.
/
/
/
Yes No
2.
/
/
/
Yes No
3.
/
/
/
Yes No
4.
/
/
/
Yes No
5.
/
/
/
Yes No
6.
/
/
/
Yes No
Fraud Warning (Not Applicable in AZ): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
I elect the dental coverage selected for which I am eligible. If any contribution from me is necessary to pay part of the cost of insurance. I authorize my employer to deduct
the contribution from my wages.
Date
Employee Signature:
Refusal of Group Dental Coverage: I have been offered this insurance coverage and decline to purchase it at this time. I understand that in the event I desire such
insurance at a later date, I will be required to furnish evidence of insurability at my own expense, and the company will have the right to refuse any request.
Date
Employee Signature:
Return To:
Total Dental Administrators, Inc.
2111 East Highland Avenue, Suite 250
Phoenix, AZ 85016-4735
1-888-422-1995