CITY/ST/ZIP__________________________________________________________________
CITY
STATE
ZIP
ADA#_____________________ EMAIL Address_____________________________________
DENTAL SCHOOL___________________________________ YEAR GRADUATED________
PERIODONTAL PROGRAM ___________________________ YEAR COMPLETED
________
BOARD CERTIFICATIONNo______
Yes_______
Year_________
| University Appointments |
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| Hospital Appointments |
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| 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. 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
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Phone: (516) 767-1050
Fax: (516) 883-9470
Email: executivedirector@nesp.org
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