CITY/ST/ZIP__________________________________________________________________
CITY
STATE
ZIP
ADA#_____________________ EMAIL Address_____________________________________
DENTAL SCHOOL___________________________________ YEAR GRADUATED________
PERIODONTAL PROGRAM ___________________________ YEAR COMPLETED
________
BOARD CERTIFICATIONNo______
Yes_______
Year_________
| University Appointments |
_______________________________________________ |
|
_______________________________________________ |
| Hospital Appointments |
_______________________________________________ |
|
_______________________________________________ |
| Dental Memberships |
_______________________________________________ |
|
_______________________________________________ |
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POST-GRADUATE STUDENTS - PLEASE ADD THE FOLLOWING:
Dental School PG Program _____________________________________________
Present Year of Post Graduate Studies (1) (2) (3)
Year of Post-graduate Graduation _______
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Signature_________________________________________ Date:____________________
|
Membership dues are $250 per year for Active membership. Associate member dues-non periodontist $350. There are no dues for Post-graduate membership. Please remit to: |
NESP c/o Dr. David I. Kratenstein, Exec. Dir.
184 Pond View Drive
Port Washington, New York 11050
|
Phone: (516) 767-1050
Fax: (516) 883-9470
Email: drkrat1025@aol.com |