Join TAPD

Please select the category you are requesting

Name (First and Last) *

Street Address *

Suite/Unit #

City *

Zip Code *

Day Time Phone *

Fax *

Email *

Specialty *

Texas Dental License Number *

ADA Number *

Dental Education Institution

Dental Degree *

Specialty Training Institution

Specialty Degree/Certificate

Current Texas Dental Association Component Society

Please check the areas in which you would like to be involved:

mentor program/membership

legislative/political issues

continuing education planning

Medicaid/C.H.I.P./Texas Dentists for Healthy Smiles issues

newsletter/publications/website

OtherOther