Profile | The International Dental Implant Association

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Title:

First Name:*

Middle Name:

Last Name:*

Member Status:*

Username:*

Password:*

Verify Password:*

Practice/Business Name:

Address #1:*

Address #2:

City:*

State:*

ZIP:*

Office Phone:*

Office Fax:

Cell Phone:

Office Web Site Addess(es):

Best Time to Contact:

Telephone #:

Undergraduate School:

Degree(s):

Year:

Dental School:

Degree(s):

Year:

Specialty or Post-Graduate Studies:

Degree(s):

Year:

Please Indicate Area of Practice:

General Practitioner

Periodontist

Endodontist

Oral and Maxillofacial Surgeon

Prosthodontist

Implantology

Course Name:

Number of Credit Hours:

Year:

Course Name:

Number of Credit Hours:

Year:

Course Name:

Number of Credit Hours:

Year:

Experience in Implant Dentistry:

less than 10 cases

10-49 cases

50-100 cases

more than 100 cases