Doctor Enrollment

The Nakanishi team is excited to work with your practice. We proudly provide expertly crafted crowns, bridges, dentures, partials, implant solutions, and more. All of restorations are crafted in-house at our dental laboratory in Washington. To get started, please fill out the form below.

Doctor Enrollment Form

"*" indicates required fields

How did you hear about us?*

What are you looking for in a lab partner?

Which Company or Vendor?*

Name of Friend or Colleague:*

When and Where was the Seminar?*

Please specify where you heard about us:*

Doctor Information

Doctor Name*

First Last

License Number*

Cell Phone*

Email*

Are You The Financially Responsible Party?*

Yes

Financially Responsible Party Name*

First Last

Financially Responsible Party Address*

Street Address City State ZIP / Postal Code

Financially Responsible Phone*

Financially Responsible Party Email*

Practice Info

Practice Name*

Address*

Street Address City State Zip Code

Phone*

Hours*

Office Staff

Office Manager

Front Office

Assistants

Hygienists

Is your practice part of a group?*

Yes

Name of group*

What type of impression are you using?*

Traditional

Digital

Please Choose A Digital impression Type

Please keep me updated on the latest lab news including upcoming CE opportunities.

Yes

SMS Consent*

I consent to receiving communications from Nakanishi Dental Lab at the provided phone number.

This field is for validation purposes and should be left unchanged.