Title: Clinic Identified M.D. D.M.D. D.D.S. Unknown
First Name: ,Last Name:

Group or Practice:
Street Address:
Suite/Room #:
City:
State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:
Contact:
Phone: Fax:
TTY:
E-Mail:
Internet:

Additional Office: None Reported Additional Practice Clinic Neighborhood Health Center
Group or Practice:
Street Address:
Suite/Room #:
City:
State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:
Phone #:
Fax:
TTY:
E-Mail:
Internet:

Narrative:

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Specialty/Specialties: EndodonticsPediatric Dentistry
General DentistryPeriodontics
Oral SurgeryProsthodontics
Orthodontics

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Education:
Certification:
Hospital Affiliation(s):

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Reimbursement at Primary Office: MassHealthSelf-pay
MedicareSliding Scale
Private Insurance

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Reimbursement through Clinic/Health Center: MassHealthSelf-pay
MedicareSliding Scale
Private Insurance

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Office Hours:

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Sedative Agents (Primary Office) Nitrous OxideIntravenous/Intramuscular Sedatives
Oral PremedicationGeneral Anesthesia

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Sedative Agents (Additional Office) Nitrous OxideIntravenous/Intramuscular Sedatives
Oral PremedicationGeneral Anesthesia

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Services Off-site: Services at Nursing HomesHome Visits

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Access Features: Able to serve clients in their wheelchair at Additional SiteLatex Free Environment at Private Office
Able to serve clients in their wheelchair at Private OfficeMercury Free Environment at Additional Site
ASL at Additional SiteMercury Free Environment at Private Office
ASL at Private OfficeMobile Equipment at Additional Site
Bathroom Wheelchair Access at Additional SiteMobile Equipment at Private Office
Bathroom Wheelchair Access at Private OfficePanorex X-Ray at Additional Site
Designated HCP Parking at Additional SitePanorex X-Ray at Private Office
Designated HCP Parking at Private OfficePublic Transportation at Additional Site
Easy Transfer Dental Chair at Additional SitePublic Transportation at Private Office
Easy Transfer Dental Chair at Private OfficeWheelchair Access at Additional Site
Latex Free Environment at Additional SiteWheelchair Access at Private Office Other Access Features:

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Populations Categories Served: PhysicalBehavioral
CognitiveOther

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Experienced with populations: AIDS/HIVElderly Person with disabilities
Asperger's SyndromeEpilepsy/Seizure Disorder
Attention Deficit Disorder/Hyper Activity DisorderIntellectual Disabilities
Autism SpectrumLanguage Impairment
Behavior DisorderMental Health
BlindMultiple Disability
Brain/Head InjuryOral/Touch Defensive
Chronic DiseaseOther See Narrative
DeafPhysical Disabilities
DeafBlindPost Traumatic Stress Disorder
Developmental DisabilitySpeech Impairment
Dual Diagnosis - ID/MI

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Willing to Treat: AIDS/HIVElderly Person with disabilities
Asperger's SyndromeEpilepsy/Seizure Disorder
Attention Deficit Disorder/Hyper Activity DisorderIntellectual Disabilities
Autism SpectrumLanguage Impairment
Behavior DisorderMental Health
BlindMultiple Disability
Brain/Head InjuryOral/Touch Defensive
Chronic DiseaseOther See Narrative
DeafPhysical Disabilities
DeafBlindPost Traumatic Stress Disorder
Developmental DisabilitySpeech Impairment
Dual Diagnosis - ID/MI

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Number of Patients seen/year/category: Physical: 1- 5
Physical: 5-10
Physical: 10-20
Physical: >20 Cognitive 1-5
Cognitive: 5-10
Cognitive: 10-20
Cognitive: >20 Behavioral: 1-5
Behavioral: 5-10
Behavioral: 10-20
Behavioral: >20 Other: 1-5
Other: 5-10
Other: 10-20
Other: >20

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Level of Experience: 1. Extensive
2. Moderate
3. Minimal
4. None

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Behavior Management Techniques: Communicative ManagementNitrous Oxide & Oxygen Inhalation Sedation
Conscious SedationPhysical Restraint
Hand Over MouthGeneral Anesthesia

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Hygienist with Disability Experience: YesNo If yes, name:

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Languages spoken: AfganiFarsiHmongPunjabi
American Sign LanguageFrenchIranianPushta
ArabicGermanItalianRussian
ArmenianGreekJapaneseSpanish
BengaliGujaratiKoreanThai
Cambodian/KhmerHaitianLaotianUrdu
Cape VerdeanHaitian-CreolePolishVietnamese
Chinese-CantoneseHebrewPortugueseTaiwanese
Chinese-MandarinHindiPortuguese-CreoleSwedish Other Language:

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Age groups served: <11 yrs19-64 yrs
11-18 yrs65+ yrs

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