Delta Dental

Customer Service Inquiry

The administering Delta Dental Member Company for the state of OH is: Delta Dental of Ohio
	Customer Service Phone Number(s): 800-524-0149 FAX: 614-890-1274 E-mail: csmail@ddpoh.com Mailing Address: 550 Polaris Parkway, Suite 550 Westerville, OH 43082

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:	- -