CSR Admin

Dental Portal Internal Administrator User Information

First Name:

Last Name:

Email Address:

*Dentist First Name:

*Dentist Last Name:

*Business Tax ID:

*Business Zip:

* Indicates a required field.

Please select the dentist name and address below that requested to have a user relationship terminated. Once you select a dentist we will search for all users with a current active relationship to that dentist.

{{item.providerName.fullName}}
{{item.providerAddress.addressLine1}}
{{item.providerAddress.city}} {{item.providerAddress.state}} {{item.providerAddress.zip5}}
Practitioner ID: {{item.providerIdentifiers.providerId}}

{{item.name.givenName}} {{item.name.middleName}}{{item.name.familyName}}
OPTUM ID: {{item.userName}}

Optum ID: {{resource.userName}}
User: {{resource.name.givenName}} {{resource.name.middleName}}{{resource.name.familyName}}