Enroll Today

American Dental Plan offers "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 email id cards upon processing.

If you are renewing your current membership, you may also print and fax this renewal form to (480) 696-7189 or mail to:

American Dental Plan
P.O. Box 13254
Scottsdale, AZ 85267

Make check payable to: American Dental Plan

Should you have any questions, or wish to enroll by phone, please call (602) 265-6677. The administrative office is currently virtual. If we are unable to answer your call, please leave a message and your call will be returned at our soonest opportunity.

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:
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