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(Step 1/3)
Korean American Dental Association
New Dentist Member (Individual)
Registration Form
Contact Information:
Name
Gender
Male
Female
Email
Phone
Practice Address
Practice Type
Private
Corporate / Large Group Practice
Community Health
Academia / Dental School
Size of Practice
1-5 Staff
6-10 Staff
11-25 Staff
26+ Staff
Undergraduate School
Dental School
Specialty
Years in Practice
Years as an ADA Member
What information(s) are you most interested in obtaining?
Practice Management
Clinical Techniques
Work/Life Balance
Corporate vs Private Practice
Other
Tell us about yourself! What are your interests outside of dentistry?
Certification
I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge. I also understand that any false statements or deliberate omissions on this form may subject me to legal actions for fraudulent misrepresentation.
Submit & Go to Step 2
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