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First Name:
Last Name:
OfficePhone #:
-
Cell Phone #:
-
Email:
Practice City:
Practice State:
AL
AK
AZ
AR
CA
CO
DE
FL
GA
HI
ID
IL
IN
IA
KA
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Practice Zip:
Reduced Hot Pract. Deal?:
(
Only say "yes" if you are advertising your practice 20% below the appraised value)
Type of Practice:
General Dentist
Endodontic
Prothedontic
Orthodontic
Oral Surgical
# Yrs Practice in Business
Number of Operatories:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25+
Avg Last 3 Yr. Gross Profit
Days Per Week Open:
Comments:
Active Pts on File:
:
Caseload Type:
Procedure Types:
Building Highlights:
Equipment Highlights:
Current Staff :
Insurance/ Reimb. Types
:
Major Business in Area:
Recreation Highlights:
City Highlights:
Practice Comments
:
BROKERAGE INFORMATION
Brokers Name:
Brokerage Company:
Broker Phone:
Practice Appraised Value:
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Additional Comments:
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