Delta Dental

Customer Service Inquiry

The administering Delta Dental Member Company for the state of NY is: Delta Dental of Pennsylvania
	Customer Service Phone Number(s): 800-932-0783 717-766-8500 FAX: 717-766-8719 Mailing Address: One Delta Drive Mechanicsburg, PA 17055 Website: www.midatlanticdeltadental.com

Please feel free to contact this Member Company by entering and sending the information in the form below. Required fields are indicated with an asterisk (*).

1. What is it that you are inquiring about?

*Message:

2. Patient Information

	First Name:
	Last Name:
	Group No:
	Claim No:

3. Who should we respond to?

	*First Name:
	Middle Initial:
	*Last Name:
	Subscriber ID No:

4. What Employer/Group provides your dental benefits?

Employer/Group Name:

5. Where are you located?

	Street Address:
	Street Address 2:
	City:
	*State:
	*Zip Code:
	Country:

6. How may we contact you?

	*E-mail:
	*Daytime Phone:	- -
	Evening Phone:	- -