Enroll Today

American Dental Plan offers continual "Open Enrollment". Just complete the form listed below, make sure to include your dental center selection and bank card information, and then click the SUBMIT button at the bottom of the page. We will reply to receiving your application and will mail your membership packet the next business day.

You may also print this form and either fax to (480) 696-7189 or mail to:

American Dental Plan
P.O. Box 44227
Phoenix, AZ 85064

Make check payable to: American Dental Plan

Should you experience any difficulties, or wish to enroll by phone, please contact Customer Service, Mon-Fri, at (602) 265-6677, between 8:30 am and 3 pm MST

Enrollee Information
Agent/Promotion Code:         
Insert the code that you were given by an agent or special promotion on a brochure.
First name:   Middle initial 
Last name:
Date of Birth:
Street Addr:
Apt/Suite:
City:
State:
Zip:
Daytime Phone:
Email:
Membership card type:   
Employer Association:
Step 1 of 6: