Select Plan1 709s - fop89.org · PDF fileQuarter 2012. Mid-Atlantic includes D.C., ... D6545 Retainer - cast metal for resin bonded fixed prosthesis ... , three or more surfaces

Select Plan (Same as a DHMO)1

• Chooseanyin-networkdentistfromoneof thelargestDHMO-stylenetworksinthe Mid-Atlantic3

• Familymembersmayselectdifferentdentists• Allnetworkdentistsarelicensed,regulated andmustmeetDominion’sCredentialingand QualityAssuranceProgramstandards• Qualitycareatpredeterminedfees• Extensivecoverageforover250procedures• Nochargefororalexams,routinesemi-annual cleanings,bitewingandcompleteseriesX-rays, topicalfluorideforchildrenoramalgamfillings (silver)• Additionalcleaningcoveredfordiabetesand expectingmothers• Orthodonticbenefitsprovidedforadultsand children• Specialtycareisprovidedatthelistedcopayment whetherperformedbyaparticipatinggeneral dentistoraparticipatingspecialist.Referrals toaspecialistmustbemadebythemember’s participatinggeneraldentist.• Out-of-AreaEmergencyCare:Youarecovered upto$100forpalliativeemergencydental treatmentarisingfromaccidentalinjuryor illnesswhiletemporarilymorethan50miles fromhome.The$100limitdoesnotapply inPennsylvania.• 15%discountonallimplantservices

Select Plan1 709sGreat value, fixed fees and special features!

Savings Comparison

Procedure Average Charge4 Your Fee Your

SavingsOral Exam $86 No Charge 100%Bitewing X-rays (2 Films) $40 No Charge 100%Topical Fluoride for Children $42 No Charge 100%Semiannual Cleaning $90 No Charge 100%Complete Series X-rays $130 No Charge 100%Filling (3-Surface/Silver) $194 No Charge 100%Root Canal (Anterior Tooth) $897 $238 73%Perio Scaling/Root Planing $247 $78 68%Crown (Porcelain/Metal) $1,210 $339 72%Complete Denture $1,493 $520 65%Extraction, Erupted Tooth $139 $39 72%Child Orthodontics $6,244 $3,422 45%Adult Orthodontics $6,244 $3,658 41%

1 Same as a DHMO plan with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pre-treatment estimates and no claim forms (except in the case of out-of-area emergencies). 2 Out-of-area emergency care reimbursement requires a receipt or other proof of loss.3 Dominion Dental Services, Inc. Competitive Network Survey, 4th Quarter 2012. Mid-Atlantic includes D.C., Delaware, Maryland, Pennsylvania and Virginia. Participating dentists are subject to change.4 Based on the Captiva context fee schedule’s 80th percentile fee information.

For full details of the coverages, limitations and exclusions, please read the enclosed Description of

Benefits and Member Copayments.

Need to find a participating dentist? Simply visit DominionDental.com.

Plan FeaturesNO Annual MaximumsNO DeductiblesNO Waiting PeriodsNO Claim Forms2

NO Pre-authorization PaperworkNO Pre-existing Condition Exclusions

We Work For Your Benefit.

®

How do I enroll?1. Completetheenclosedenrollmentcard.

• Listalldependentsyouwantcovered.• Youmustchooseaprimarycaredentistbefore

orafterenrollment.YoucanfindacurrentlistofdentistsonlineatDominionDental.com/find-

a-dentist.Youcanalsocallusat888-518-5338torequestthatonebemailedtoyou.Afteryoureffectivedate,simplycallthedentalofficeyou selectedandmakeanappointment.Exceptforout-of-areaemergencycare,youmustreceivetreatmentatthedentalofficeyouselected.

2. ReturnthecompletedenrollmentcardtoyourBenefitAdministratororasdirected.

3. AMembershipCard,DescriptionofBenefitsandMemberCopaymentsandCertificateofCoveragewillbemailedtoyouonorbeforeyourfirstdayofeligibility.

4. Ifyouhaveanyquestionsregardingyourdateofeligibility,pleasecontactyourBenefitsDepartment.

Who is eligible?Youandyourdependentsareeligible.Dependentsincludeyourspouseandunmarriedchildrenunderage26.Refertoyourpolicydocumentsforfurtherdetailsregardingyourdependentcoverage.

What if I change jobs?Ifyouleaveyourplaceofemployment,youhavetheoptionofconvertingyourcoveragetoanalternateDominionprogramusingadifferentmethodofpayment.

Can I make changes on the Internet?Yes.Dominionprovidesmemberswithsecureonlineaccessto:• IDcardrequests• Planinformation• Dentistsearch• Dentalofficetransfers• Contactinformation• Memberservicesrequestsandgeneral

correspondence

Allchangesareconfirmedbyreturnemail.Formoreinformation,visitDominionDental.com.

115 South Union Street, Suite 300Alexandria, VA 22314888-518-5338 (Phone)855-485-0115 (Fax)DominionDental.com

We Work For Your Benefit.® Dominion Dental Services (Dominion)is an agile and innovative administrator of dental and vision benefits in the Mid-Atlantic, offering managed care and indemnity programs, claims adjudication and comprehensive plan administration. Among our 500,000 customers are leading health plans, employer groups, municipalities, associations and individuals. The Dominion group of companies includes Dominion Dental Services, Inc., a licensed issuer of dental plans, and Dominion Dental Services USA, Inc., a licensed administrator of dental and vision benefits.

0112

A New Level of Service1

• Less than 0.1% of our memberscalled with a service issue.

• ID cards and member packetswere mailed within 4 days ofenrollment.

• 98% member retention rate.

• 97% of Dominion membershave access to at least twoSelect Plan dentists within10 miles.

1 Dominion Dental Services, Inc. Internal Performance Report, 2012

What is my monthly cost?1

SubscriberOnly $32.08SubscriberandFamily $73.601Includes $1.00 Dominion/FOP administrative fee and $2.10 Prince George’s County

direct withdrawal processing fee.

Dominion Dental Services, Inc. is licensed as a Dental Plan Organization in Virginia, Maryland and Delaware, a Risk Assuming PPO in Pennsylvania and an Accident and Health Insurer in D.C.

®

DENTAL SELECT PLAN ENROLLMENT CARD

Last Name First Name M.I.

Social Security Number Sex M F Birthdate (MM/DD/YY)

Home Address Home Phone

City State ZIP Work Phone

Email Address Hire Date

Dental Office Name & Code # (As indicated on Your Dentist Directory)

List All Your Eligible Dependents Below

Last Name (if different) First Name M.I.. Social SecurityNumber

Sex (M/F)

Birthdate (MM/DD/YY)

Spouse

Child

Child

Child

Child

Child

Child If I am voluntarily paying 100% of the cost of this Plan, without employer contribution, I agree to remain in Plan a minimum of twelve (12) months. If I cancel before the end of the 12 month period, I may be responsible for the usual, customary and reasonable charges for services received, reduced by the sum of the subscription dues and copayments paid.

I understand and agree that my signature on this enrollment form serves as my legal commitment to the Plan and its terms. Further, this signature represents my authorization for the release of information regarding services provided to me or my covered dependents by dentists and other providers of dental services. Information will be released to Dominion Dental Services, Inc., for the purpose of investigation or evaluation of care in connection with a claim or complaint. Authorization will be limited to the term of coverage of this contract. A copy of this form will be made available to subscriber or their authorized representative upon request.

Signature _____________________________________________________________ Date _______________PAPERLESS? Yes NoAgent/Broker # Group # Group Name Coverage Eff. Date

Dominion Dental Services, P.O. Box 75314 Charlotte, NC 28275-5314

Delaware - Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony. District of Columbia - WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Maryland - Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Pennsylvania - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information,or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Virginia - It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

12DAPP

Dominion Dental Services, Inc.Alexandria, VA

Prince George’s County FOP

D2720/21/22 Crown-resinwithmetal................................................ 305D2740 Crown-porcelain/ceramicsubstrate............................. 376D2750/51/52 Crown-porcelainfusedmetal....................................... 339D2780/81/82 Crown-3/4castwithmetal........................................... 309D2783 Crown-3/4porcelain/ceramic....................................... 315D2790/91/92 Crown-fullcastmetal................................................... 325D2910/20 Recementinlay,onlay/crownorpartialcoveragerest..... 28D2930 Prefab.stainlesssteelcrown-prim.tooth....................... 75D2931 Prefab.stainlesssteelcrown-perm.tooth...................... 82D2932 Prefabricatedresincrown................................................ 91D2950 Corebuildup,includinganypins...................................... 80D2952 Castpostandcoreinadditiontocrown......................... 109D2954 Prefab.postandcoreinadditiontocrown...................... 87D2955 Postremoval(notinconj.withendo.therapy)................. 68D2970 Temporarycrown(fracturedtooth)..................................... 0D2980 Crownrepair,byreport.................................................... 60 PROSTHETICS (DENTURES)D5110/20 Completedenture-maxillary/mandibular...................... 520D5130/40 Immediatedenture-maxillary/mandibular..................... 534D5211/12 Maxillary/mandibularpartialdenture-resinbase.......... 520D5213/14 Maxillary/mandibularpartialdenture-castmetal.......... 534D5225/26 Maxillary/mandibularpartialdenture-flexiblebase....... 534D5281 Rem.unilateralpartialdenture-onepiececastmetal.. 296D5410/11 Adjustcompletedenture-maxillary/mandibular.............. 23D5421/22 Adjustpartialdenture-maxillary/mandibular................... 23D5510/5610 Repairbrokendenturebase(complete/resin)................. 57D5520 Replacemissingorbrokenteeth-completedenture...... 65D5620 Repaircastframework..................................................... 65D5630/60 Clasprepaired,replacedoradded.................................. 80D5640 Replacebrokenteeth-pertooth..................................... 65D5650 Addtoothtoexistingpartialdenture................................ 65D5670/71 Replaceallteethandacryliconcastmetalframework.... 167D5710/11 Rebasecompletemaxillary/mandibulardenture............ 217D5720/21 Rebasemaxillary/mandibularpartialdenture................ 217D5730/31 Relinecompletemaxillary/mandibulardenture(chairside)...109D5740/41 Relinemaxillary/mandibularpartialdenture(chairside)... 109D5750/51 Relinecompletemaxillary/mandibulardenture(lab)...... 174D5760/61 Relinemaxillary/mandibularpartialdenture(lab).......... 174D5810/11 Interimcompletedenture-maxillary/mandibular........... 318D5820/21 Interimpartialdenture-maxillary/mandibular................ 318D5850/51 Tissueconditioning-maxillary/mandibular...................... 46 BRIDGE & PONTICS

D6000-D6199ALLIMPLANTSERVICES-15%DISCOUNT (incl.D0360-D0363conebeamimagingw/implants)D6210/11/12 Pontic-metal................................................................. 325D6240/41/42 Pontic-porcelainfusedmetal....................................... 339D6245 Pontic-porcelain/ceramic............................................. 376D6250/51/52 Pontic-resinwithmetal................................................. 305D6545 Retainer-castmetalforresinbondedfixedprosthesis... 161D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis.. 253D6600 Inlay-porc./ceramic,twosurfaces................................ 296D6601 Inlay-porc./ceramic,>=3surfaces................................ 303D6602 Inlay-casthighnoblemetal,twosurfaces.................... 276D6603 Inlay-casthighnoblemetal,>=3surfaces................... 283D6604 Inlay-castpredominantlybasemetal,twosurfaces..... 276D6605 Inlay-castpredominantlybasemetal,>=3surfaces.... 283D6606 Inlay-castnoblemetal,twosurfaces............................ 276D6607 Inlay-castnoblemetal,>=3surfaces........................... 283D6608 Onlay-porc./ceramic,twosurfaces............................... 270D6609 Onlay-porc./ceramic,threeormoresurfaces.............. 290D6610 Onlay-casthighnoblemetal,twosurfaces.................. 270D6611 Onlay-casthighnoblemetal,>=3surfaces................. 361D6612 Onlay-castpredominantlybasemetal,twosurfaces... 270D6613 Onlay-castpredominantlybasemetal,>=3surfaces... 361D6614 Onlay-castnoblemetal,twosurfaces.......................... 270D6615 Onlay-castnoblemetal,>=3surfaces......................... 361D6720/21/22 Crown-resinwithmetal................................................ 305D6740 Crown-porcelain/ceramic............................................. 376D6750/51/52 Crown-porcelainfusedmetal....................................... 339D6780 Crown-3/4casthighnoblemetal................................. 309D6781 Crown-3/4castpredominantlybasemetal.................. 309D6782 Crown-3/4castnoblemetal......................................... 309D6783 Crown-3/4porc./ceramic.............................................. 315D6790/91/92 Crown-fullcastmetal................................................... 325D6930 Recementfixedpartialdenture........................................ 44D6970 Postandcoreinadditiontofixedpart.dent.ret............ 109D6972 Prefabpostandcoreinadditiontofixedpart.dent.ret... 87

DIAGNOSTIC/PREVENTIVED9439 Officevisit.......................................................................... 0D0120 Periodicoraleval-establishedpatient.............................. 0D0140 Limitedoraleval-problemfocused................................... 0D0145 Oralevalforapatientunder3yearsofage...................... 0D0150 Comprehensiveoraleval-neworestablishedpatient...... 0D0160 Detailedandextensiveoraleval-problemfocused.......... 0D0170 Re-evaluation-limited,problemfocused.......................... 0D0210 Intraoral-completeseries(includingbitewings)................ 0D0220 Intraoral-periapicalfirstfilm.............................................. 0D0230 Intraoral-periapicaleachadd.film.................................... 0D0240 Intraoral-occlusalfilm....................................................... 0D0250/60 Extraoral-firstfilmandeachadd.film.............................. 0D0270-74 Bitewingx-rays-1to4films.............................................. 0D0277 Verticalbitewings-7to8films.......................................... 0D0330 Panoramicfilm................................................................. 25D0340 CephalometricFilm............................................................ 0D0350 Oral/facialphotographicimages........................................ 0D0460 Pulpvitalitytests................................................................ 0D0470 Diagnosticcasts................................................................. 0D1110 Prophylaxis(cleaning)-adult............................................ 0D1110* Additionalcleaning(expectingmothersorDiabetics)...... 40D1120 Prophylaxis(cleaning)-child............................................. 0D1203 Topicalapplicationoffluoride-child.................................. 0D1204 Topicalapplicationoffluoride-adult.................................. 0D1206 Topicalfluoridevarnishformod/highriskcariespatients.. 0D1310 Nutritionalcounselingforcontrolofdentaldisease........... 0D1320/30 Oralhygieneinstructions................................................... 0D1351 Sealant-pertooth........................................................... 12D1352 Prevresinrest.mod/highcariesrisk–perm.tooth......... 12 SPACEMAINTAINERSD1510/20 Spacemaintainer-fixed/removable-unilateral.............. 85D1515/25 Spacemaintainer-fixed/removable-bilateral.............. 124D1550 Re-cementationofspacemaintainer............................... 28 RESTORATIVE DENTISTRY (FILLINGS) AMALGAMRESTORATIONS(SILVER)D2140 Amalgam-onesurface,prim.orperm.............................. 0D2150 Amalgam-twosurfaces,prim.orperm............................. 0D2160 Amalgam-threesurfaces,prim.orperm.......................... 0D2161 Amalgam->=4surfaces,prim.orperm............................ 0 RESIN/COMPOSITERESTORATIONS(TOOTHCOLORED)D2330 Resin-basedcomposite-onesurface,anterior............... 39D2331 Resin-basedcomposite-twosurfaces,anterior.............. 46D2332 Resin-basedcomposite-threesurfaces,anterior........... 54D2335 Resin-basedcomposite->=4surfaces,anterior............. 64D2391 Resin-basedcomposite-onesurface,posterior............. 43D2392 Resin-basedcomposite-twosurfaces,posterior............ 49D2393 Resin-basedcomposite-threesurfaces,posterior......... 58D2394 Resin-basedcomposite->=4surfaces,posterior........... 68 D2940 Sedativefilling.................................................................. 28D2951 Pinretention-pertooth,inadditiontorestoration........... 16D3110/20 Pulpcap-direct/indirect(excl.finalrestoration).............. 20 CROWN & BRIDGE

D2390 Resin-basedcompositecrown,anterior........................ 109D2510 Inlay-metallic-onesurface.......................................... 276D2520 Inlay-metallic-twosurfaces........................................ 276D2530 Inlay-metallic-threeormoresurfaces........................ 283D2542 Onlay-metallic-twosurfaces......................................... 270D2543 Onlay-metallic-threesurfaces...................................... 361D2544 Onlay-metallic-fourormoresurfaces........................... 361D2610 Inlay-porcelain/ceramic-onesurface.......................... 296D2620 Inlay-porcelain/ceramic-twosurfaces........................ 296D2630 Inlay-porcelain/ceramic->=3surfaces........................ 303D2642 Onlay-porcelain/ceramic-twosurfaces....................... 270D2643 Onlay-porcelain/ceramic-threesurfaces.................... 290D2644 Onlay-porcelain/ceramic->=4surfaces...................... 290D2650 Inlay-resin-basedcomposite-onesurface.................. 299D2651 Inlay-resin-basedcomposite-twosurfaces................ 299D2652 Inlay-resin-basedcomposite->=3surfaces................ 299D2662 Onlay-resin-basedcomposite-twosurfaces............... 320D2663 Onlay-resin-basedcomposite-threesurfaces............ 320D2664 Onlay-resin-basedcomposite->=4surfaces.............. 320D2710 Crown-resinbasedcomposite(indirect)...................... 166D2712 Crown-3/4resin-basedcomposite(indirect)................ 312

Plan 709sDescription of Benefits & Member Copayments

Form700-2012 Allfeesexcludethecostofnobleandpreciousmetals.Anadditionalfeewillbechargedifthesematerialsareused.

ADA MEMBERCODE BENEFIT COPAYMENT(S)


ORTHODONTICS2

D8660 Pre-orthodontictreatmentvisit....................................... 413D8070 Comp.ortho.treatment-transitionaldentition............. 3304D8080 Comp.ortho.treatment-adolescentdentition............. 3422D8090 Comp.ortho.treatment-adultdentition...................... 3658D8670 Periodicortho.treatmentvisit(aspartofcontract)........ 118D8680 Orthodonticretention(rem.ofappl.andplacement ofretainer(s))............................................................. 413 2 Phase I Treatment (D8010 - D8050) is provided at a 15% reduction from the orthodontist’s UCR fees. See exclusion #15 for additional coverage exclusions.

D6973 Corebuildupforretainer,includinganypins................... 72D6975 Coping-metal............................................................... 182D6976 Eachadd.indirectlyfabricatedpost-sametooth............ 73D6977 Eachadd.prefabpost-sametooth................................. 34D6980 Fixedpartialdenturerepair,byreport.............................. 96 ADJUNCTIVE GENERAL SERVICESD9110 Palliative(emergency)treatmentofdentalpain.............. 35D9210/15 Localanesthesia................................................................ 0D9211 Regionalblockanesthesia................................................. 0D9212 Trigeminaldivisionblockanesthesia................................. 0D9220 Deepsedation/generalanesthesia-first30min........... 205D9221 Deepsedation/generalanesthesia-eachadd.15min.103D9241 Intravenousconscioussedation/analgesia-first30min....205D9242 IVconscioussedation/analgesia-eachadd.15min..... 103D9230 Analgesia,anxiolysis,inhalationofnitrousoxide............. 30D9310 Consultation(diagnosticservicebynontreatingdentist)... 36D9910 Applicationofdesensitizingmedicament......................... 18D9930 Treatmentofcomplications(post-surgical)...................... 33D9990 Brokenofficeappointment............................................... 50 ENDODONTICS1

D3220 Therapeuticpulpotomy(excl.finalrestor.)....................... 50D3221 Pulpaldebridement,prim.andperm.teeth...................... 52D3310 Endodontictherapy,anteriortooth................................. 238D3320 Endodontictherapy,bicuspidtooth................................ 319D3330 Endodontictherapy,molar............................................. 386D3333 Internalrootrepairofperforationdefects......................... 59D3346 Retreatofprev.rootcanaltherapy,anterior................... 268D3347 Retreatofprev.rootcanaltherapy,bicuspid.................. 341D3348 Retreatofprev.rootcanaltherapy,molar...................... 408D3410 Apicoectomy/periradicularsurgery,anterior................... 193D3421 Apicoectomy/periradicularsurgery,bicuspid(firstroot)... 223D3425 Apicoectomy/periradicularsurgery,molar(firstroot)..... 238D3426 Apicoectomy/periradicularsurgery(eachadd.root)...... 104D3430 Retrogradefilling-perroot.............................................. 74D3450 Rootamputation-perroot............................................. 141D3920 Hemisection,notinc.rootcanaltherapy........................ 141D3950 Canalprep/fittingofpreformeddowelorpost................ 104 PERIODONTICS1

D0180 Comp.periodontaleval-neworestablishedpatient....... 35D4210 Gingivectomyorgingivoplasty->3cont.teeth,perquad.....190D4211 Gingivectomyorgingivoplasty-<=3teeth,perquad...... 57D4240 Gingivalflapproc.,inc.rootplaning- >3cont.teeth,perquad............................................. 246D4241 Gingivalflapproc,inc.rootplaning- <=3cont.teeth,perquad............................................. 57D4260 Osseoussurgery->3cont.teeth,perquad.................. 366D4261 Osseoussurgery-<=3cont.teeth,perquad................ 220D4268 Surgicalrevisionproc.,pertooth................................... 201D4274 Distalorproximalwedgeprocedure.............................. 176D4341 Perioscalingandrootplaning->3contteeth,perquad... 78D4342 Perioscalingandrootplaning-<=3teeth,perquad...... 35D4355 Fullmouthdebridement................................................... 61D4381 Localizeddeliveryofchemotherapeuticagents............... 55D4910 Periodontalmaintenance................................................. 58D9940 Occlusalguard,byreport............................................... 195D9950 Occlusionanalysis-mountedcase................................. 42D9951 Occlusaladjustment-limited........................................... 39D9952 Occlusaladjustment-complete..................................... 156 ORAL SURGERY1

D7111 Extraction,coronalremnants-deciduoustooth............ 106D7140 Extraction,eruptedtoothorexposedroot........................ 39D7210 Surgicalrem.oferuptedtoothreq.bonecut................... 87D7220 Removalofimpactedtooth-softtissue......................... 112D7230 Removalofimpactedtooth-partiallybony.................... 116D7240 Removalofimpactedtooth-completelybony............... 152D7241 Removalofimp.tooth-completelybony, withunusualsurg.complications............................... 145D7250 Surgicalremovalofresidualtoothroots........................ 102D7270 Toothreimplant./stabiliz.ofacc.evulsed/displacedtooth...137D7280 Surgicalaccessofanuneruptedtooth............................ 71D7291 Transseptalfiberotomy/supracrestalfiberotomy,byreport....27D7310/20 Alveoloplasty,perquad.................................................... 80D7510 Incisionanddrainageofabscess-intraoralsofttissue... 58D7960 Frenulectomy(frenectomy/frenotomy)-separateproc.. 120 1Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Specialist. Referrals to a specialist must be made by a member’s Participating General Dentist. See Plan Exclusion #13.

Plan 709s

Plan Exclusions1. Services which are covered under Medicare, worker’s compensation, employer’s liability laws, or the Pennsylvania Motor Vehicle Financial ResponsibilityLaw(Pennsylvaniapolicyholdersonly).2. Serviceswhich,intheopinionoftheattendingdentist,arenotnecessary forthepatient’sdentalhealth.3. Cosmetic, elective or aesthetic dentistry except as required due to accidentalbodilyinjurytosoundnaturalteeth.4. Oralsurgeryrequiringthesettingoffracturesordislocations.5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, anodontic, mandibular prognathism or development malformations where, in the opinion of the Participating Dentist, suchservicesshouldnotbeperformedinadentaloffice.6. Dispensingofdrugs.7. Hospitalizationforanydentalprocedure.8. Treatmentrequiredforconditionsresultingfrommajordisaster,epidemic, war, acts of war, whether declared or undeclared, or while on active dutyasamemberofthearmedforcesofanynation.9. Replacementduetolossortheftofprostheticappliance.10. ProceduresnotlistedascoveredbenefitsunderthisPlan.11. Services obtained outside of the dental office in which enrolled and that are not preauthorizedby such office or Dominion Dental Services, Inc.(withtheexceptionofout-of-areaemergencydentalservices).12. ServicesrelatedtothetreatmentofTMD(TemporomandibularDisorder).13. Services performed by a Participating Specialist without a referral from

a Participating General Dentist (with the exception of Orthodontics). AreferralformisonlyrequiredinMaryland.ParticipatingdentistsshouldrefertoSpecialtyCareReferralGuidelines.

14. Elective surgery including, but not limited to, extraction of non- pathologic,asymptomaticimpactedteeth.15. The Invisalign system and similar specialized braces are not a covered benefit. Patient copaymentswill apply to the routineorthodontic appliance portionofservicesonly. Additionalcosts incurredwillbecome thepatient’s responsibility.Plan Limitations1. Two(2)evaluationsarecoveredpercalendaryearincludingamaximumof one(1)comprehensiveevaluation.2. One(1)problemfocusedexamiscoveredpercalendaryear.3. Two(2)teethcleanings(prophylaxis)arecoveredpercalendaryear(one additionalcleaningiscoveredduringpregnancyandfordiabeticpatients).4. One(1)topicalfluorideorfluoridevarnishiscoveredpercalendaryear.5. Two(2)bitewingx-raysarecoveredpercalendaryear.6. One (1) set of full mouth x-rays or panoramic film is covered every three(3)years.7. One(1)sealantorpreventativeresinrestorationpertoothiscoveredper lifetime,uptoage16(limitedtopermanent1stand2ndmolars).8. Replacementofafillingiscoveredifitismorethantwo(2)yearsfromthe dateoforiginalplacement.9. Replacement of a bridge, crownor denture is covered if it ismore than seven(7)yearsfromthedateoforiginalplacement.10. Crown and bridge fees apply to treatment involving five or fewer units when presented in a single treatment plan. Additional crown or bridge units,beginningwith thesixthunit,areavailableat theprovider’sUsual, Customary,andReasonable(UCR)fee,minus25%.11. Reliningandrebasingofdenturesiscoveredonceevery24months.12. Retreatmentofrootcanal iscoveredif it ismorethantwo(2)yearsfrom theoriginaltreatment.13. Rootplaningorscalingiscoveredonceevery24monthsperquadrant.14. Fullmouthdebridementiscoveredonceperlifetime.15. ProcedureCodeD4381islimitedtoone(1)benefitpertoothforthreeteeth perquadrantora totalof12 teeth forall fourquadrantsper twelve (12) months.Musthavepocketdepthsoffive(5)millimetersorgreater.16. Periodontalsurgeryofanytype,includinganyassociatedmaterial,iscovered onceevery36monthsperquadrantorsurgicalsite.17. Periodontalmaintenanceafteractivetherapyiscoveredtwicepercalendar year,within24monthsafterdefinitiveperiodontaltherapy.OnlycurrentADACDTcodesareconsideredvalidbyDominionDentalServices,Inc.Current Dental Terminology © American Dental Association.



Dominion Dental Services, Inc. • 115 South Union Street • Suite 300 • Alexandria, VA 22314

(703) 518-5338 • Toll Free (888) 518-5338 • Fax (855) 485-0115 • DominionDental.comPage 1As of 9/1/2013

Washington / Baltimore Metropolitan Area

Select PlAn1 DentiSt DirectoryGeneral Dentists

We are continually expanding our network of dentists. For the most up-to-date listing of all participating general dentists and specialists visit us on the web at DominionDental.com. A printed list can also be requested by calling our Member Services Department toll-free at 888-518-5338.

*Not accepting new members.†6000x and 5000x Program not accepted.

‡6000x and 5000x Program only.

1Same as a DHMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pre-treatment estimates and no claim forms (except in the case of out-of-area emergencies)

VirGiniAAlexAnDriA cityAlexandria

#50340 (571) 970-3783 Alexandria Dental Care PLLC 715 Pendleton St Alexandria, VA 22314

#144 (703) 823-2413 Bright Now Dental 5249 Duke St, Ste 210 Alexandria, VA 22304

#145747 (703) 751-7000 Landmark Dental Care 101 S Whitting St, Ste 100 Alexandria, VA 22304

#239 (703) 823-8812 Nathan Tsui DDS 5249 Duke St, Ste 10 Alexandria, VA 22304

#2274 (703) 931-6344 Phuong Phan D.MD PC 1225 Martha Custis Dr, #C-6 Alexandria, VA 22302

#215 (703) 379-2290 Ronald E Tolson DDS 5246 Dawes Ave Alexandria, VA 22311

#1269 (703) 914-0020 Said M Khalefa DDS PC 4600 Pincrest Office Park Dr, Ste B Alexandria, VA 22312

#136030 (703) 578-4221 Smiley Du Dental 3610 Forest Dr, Ste 4A Alexandria, VA 22302

#342 (703) 751-1112 Thomas S. Kwon, D.D.S. 4701 Kenmore Ave, Ste 122 Alexandria, VA 22304

ArlinGton countyArlington

#233 (703) 525-0233 Carl G Lebo DDS PC 3801 N Fairfax Dr, Ste 72 Arlington, VA 22203

#127008 (703) 525-3131 Elegant Smiles Dental Care 3801 N Fairfax Dr, Ste 42 Arlington, VA 22203

#37711 (703) 807-0808 Mira Dental Care 1901 N Moore St, Ste 501 Arlington, VA 22209

FAirFAx countyAlexandria

#78281 (703) 750-1099 Elegant Smiles Dental Care 4810 Beauregard St, Ste 300 Alexandria, VA 22312

#50839* (703) 822-0670 Impression Dental Inc. 6167 Fuller Ct Alexandria, VA 22310

#50919 (703) 719-9210 Kingstowne Family & Cosmetic Dentistry 5960 Kingstowne Town Center, Ste 140 Alexandria, VA 22315

#1891 (703) 768-9400 Virginia Dental Center 6230-C N King’s Hwy Alexandria, VA 22303

Annandale

#61339 (703) 256-3589 Navdeep Aulakh DDS PLLC 4231 Markham St, Ste 214 Annandale, VA 22003

#50376 (703) 942-6612 Springdale Dentistry 5105 C Backlick Rd Annandale, VA 22003

Burke

#50466 (703) 978-7900 Alireza Palizi DDS PC 5216-A Lyngate Ct Burke, VA 22015

#50454 (703) 323-9394 Dental First Associates LLC 9570-A Burke Rd Burke, VA 22015

#74 (703) 250-5790 Hashem Sedaghatpour, D.M.D. 5631-D Burke Centre Pkwy Burke, VA 22015

#37680 (703) 425-1846 Young Smile Dental 9000 Fern Park Dr, A2 Burke, VA 22015

centreville

#147129 (703) 447-5204 Brite Smile Dental Group 14631 Lee Hwy, Ste 116 Centreville, VA 20121

#1452* (703) 266-2000 Jim J. Soltani, D.D.S. & Associates, P.C. 6019 Centreville Crest Ln Centreville, VA 20121

#61402 (703) 815-0007 V Care Dental LLC 14631 Lee Hwy, Ste 117 Centreville, VA 20121

chantilly

#37667* (703) 773-1212 Diamond Dental Care 13948 Lee Jackson Memorial Hwy Chantilly, VA 20151

#1387* (703) 378-1695 Donald Chaenkwok, D.D.S. 14012B Sullyfield Cir Chantilly, VA 20151

#141822 (703) 870-7784 Grace Dental of Virginia 4530 Walney Rd, Ste 102 Chantilly, VA 20151

Fairfax

#2529 (703) 766-1575 Chuck C. Joo, D.M.D. 12011 Lee Jackson Mem. Hwy, 104 Fairfax, VA 22033

#523 (703) 425-3737 Howard Hoffman DDS PC 9661 C Main St Fairfax, VA 22031

#50398 (703) 352-2810 Minjeong Suk DDS PC 4001 Fair Ridge Dr, Ste 105 Fairfax, VA 22033

#144421 (703) 263-9388 Westfields Dental 3903 Fair Ridge Dr, Ste 214 Fairfax, VA 22033

Falls church

#50547 (703) 532-4400 Apt Dental Associates 7115 Leesburg Pk, Ste 216 Falls Church, VA 22043

#33844 (703) 237-0060 Arlington Dental Care PLLC 6060 Arlington Blvd Falls Church, VA 22044

#815 (703) 821-8111 Drs. Seigel & Moller 7641 Leesburg Pk Falls Church, VA 22043

#1103 (703) 534-6500 Drs. Whiston, Patterson & Corcoran 6400 Arlington Blvd, Plaza 1 Lower Level Falls Church, VA 22044

#2845 (703) 534-7900 Falls Church Family and Comprehensive Dentistry 6400 Arlington Blvd, Ste 944 Falls Church, VA 22042

#50943* (703) 933-1121 Gentle Touch Dentistry for All Ages 6521 Arlington Blvd, Ste 112 Falls Church, VA 22042

#37710 (703) 845-9090 Mira Dental Care 5671 Columbia Pk, 101 Falls Church, VA 22041

#70486 (703) 992-0708 Nguyen and Associates Dental 2901 Telstar Ct, Ste 120 Falls Church, VA 22042

#2124 (703) 876-4700 Optimum Dental 7389 Lee Hwy, Ste 101 Falls Church, VA 22042

#1544 (703) 575-9700 Smile Dental Clinic 3817-A S George Mason Dr Falls Church, VA 22041

#72077 (703) 417-9622 Your Family Dentist 5666 Columbia Pk, Ste A Falls Church, VA 22041

Herndon

#92 (703) 478-0115 Bright Now Dental 13873 Park Center Rd, Ste 137 Herndon, VA 20171

Mc lean

#51125 (571) 633-9455 Mira Dental Care at Tysons Corner 8201 Greensboro Dr, Ste 710 Mc Lean, VA 22102

reston

#61412 (703) 787-3591 A B Dental 11790 H Baron Cameron Ave Reston, VA 20190

#79058 (571) 926-8429 Family and Cosmetic Dentistry 1800 Michael Faraday Dr Reston, VA 20190

#926 (703) 318-8133 Sherry Anoushfar, D.D.S., PC 1984 Isaac Newton Square, Ste 201 Reston, VA 20190

Springfield

#524 (703) 644-0080 Howard Hoffman DDS PC 6340 Brandon Ave Springfield, VA 22150

#48 (703) 451-4211 Said M. Khalefa, D.D.S., P.C. 6115 Backlick Rd Springfield, VA 22150

Vienna

#97844 (703) 757-1000 Beulah Dental 1300 Beulah Rd Vienna, VA 22182

#145 (703) 573-8664 Bright Now Dental 2230 Gallows Rd, Ste 320 Vienna, VA 22027

#115*† (703) 448-3527 Le Smile 2070 Chain Bridge Rd, Ste 530 Vienna, VA 22182

#50928 (703) 573-8664 Mazin Alayssami DMD & Associates PC Specialists 2230 Gallows Rd, Ste 320 Vienna, VA 22027

#97164 (703) 506-0800 Richard J Hong DMD PC 8230 Boone Blvd, Ste 208 Vienna, VA 22182


(703) 518-5338 • Toll Free (888) 518-5338 • Fax (855) 485-0115 • DominionDental.comPage 2As of 9/1/2013 Page 2

#1302 (703) 319-9880 Sherry Anoushfar, D.D.S., PC 133 E Maple Ave, Ste 206 Vienna, VA 22182

#33870 (703) 848-8889 Tysons Corner Dentists 8296-A Old Courthouse Rd Vienna, VA 22182

FAirFAx cityFairfax

#217 (703) 273-6622 Drs Berman & Miller DDS 9942 Main St Fairfax, VA 22031

#37738 (703) 273-7999 Family Dentistry of Fairfax, PC 10391 Democracy Ln, Ste A Fairfax, VA 22030

#37759 (703) 261-6999 Thomas Yoon Dental 10807 Main St, 200 Fairfax, VA 22030

FAllS cHurcH cityFalls church

#358* (703) 534-3177 Albert M. Boyce, D.D.S. 313 Park Ave, Ste 101 Falls Church, VA 22046

#1322 (703) 534-9200 Ali Sarraj, D.M.D. & Associates, P.C. 932 W Broad St Falls Church, VA 22046

#61384 (703) 531-0010 Dynamic Dental PC 159 Hillwood Ave Falls Church, VA 22046

FAuquier countyWarrenton

#78269 (540) 878-5903 Marlin F Rekow DDS PC 127 E Shirley Ave Warrenton, VA 20186

FreDerickSBurG cityFredericksburg

#1730 (540) 310-4986 Dental One Associates Fredericksburg PC 201 Park Hill Dr Fredericksburg, VA 22401

#68492 (540) 551-5550 Tranquility Dental Center PLLC 2557 Cowan Blvd Fredericksburg, VA 22401

louDoun countyAshburn

#37695 (703) 726-0333 Gateway Dental 44330 Premier Plaza, 140 Ashburn, VA 20147

chantilly

#37730 (703) 348-8142 South Riding Dental Associates, P.C. 25055 Riding Plaza Dr, Ste 270 Chantilly, VA 20152

leesburg

#2290 (703) 724-4220 Amirreza Rafaat, D.D.S., P.C. 19450 Deerfield Ave, Ste 465 Leesburg, VA 20176

Sterling

#157 (703) 444-7102 Bright Now Dental 6 Pidgeon Hill Dr, Ste 200 Sterling, VA 20165

#2123 (703) 421-8988 Drs Partovi & Kianpour 46396 Benedict Dr, Ste 230 Sterling, VA 20164

#1808 (703) 444-1656 Marie Hooshmand, D.D.S., P.C. 21165 Whitfield Pl, Ste 101 Sterling, VA 20165

#1912 (703) 404-1115 Truc Duong, D.D.S., PC 21145 Whitfield Pl, Ste 103 Sterling, VA 20165

MAnASSAS cityManassas

#1729 (703) 367-0599 Dental One Associates Manassas PC 7800 Sudley Rd, Ste 7810 Manassas, VA 20109

#50777 (703) 368-4725 Kevin Mendes DDS & Associates PLLC 8609 Sudley Rd, Ste 102 Manassas, VA 20110

#50778 (703) 330-5755 Kevin Mendes DDS & Associates PLLC 8404 Dorsey Cir Manassas, VA 20110

Prince WilliAM countyDale city

#2416* (703) 897-8554 Hanna Hannania, D.D.S., P.C. 4319 Dale Blvd Dale City, VA 22193

Dumfries

#51112 (703) 499-9006 The Dentist Office LLC 17865 Main St, Ste A Dumfries, VA 22026

Woodbridge

#2131 (703) 499-8888 Dental Center at Lake Ridge 12764 Darby Brooke Ct Woodbridge, VA 22192

#1731 (703) 491-4489 Dental One Associates Woodbridge PC 14520 Smoketown Rd Woodbridge, VA 22192

#456 (703) 491-2200 Joel R Braunfeld DDS 2239-L Tackett’s Mill Dr Woodbridge, VA 22192

#81562 (703) 492-1999 Light Family Dental 14416 Jefferson Davis Hwy, Ste 16 Woodbridge, VA 22191

#451* (703) 670-8400 Raymond C. Haston, Jr., D.D.S. 14393 Hereford Rd Woodbridge, VA 22193

#33879 (703) 583-7720 Sameer Kwatra, D.D.S., PC 2970 Prince William Pkwy Woodbridge, VA 22192

SPotSylVAniA countyFredericksburg

#147 (540) 785-8525 Frank D. Romano, D.D.S. 1133 Heatherstone Dr Fredericksburg, VA 22407

Spotsylvania

#37958 (540) 891-6570 Bright Now Dental 10454 Hill Top Plaza Way Spotsylvania, VA 22553

StAFForD countyFredericksburg

#428* (540) 286-1110 Raymond C Haston Jr DDS PC 560 Celebrate Virginia Pkwy, 107 Fredericksburg, VA 22406

Stafford

#128646 (540) 720-8630 Aquia Dental Care 2712 Jefferson Davis Hwy, Ste 201 Stafford, VA 22554

#156 (540) 659-6816 Bright Now Dental 392 Garrisonville Rd, Ste 205 Stafford, VA 22554

#854 (540) 659-5161 Elizabeth M Attreed DDS 2832 Jefferson Davis Hwy, Aquia Towne Center Stafford, VA 22554

DiStrict oF coluMBiAWashington

#185 (202) 463-6148 Andrew M. Lasky, D.D.S., P.C. 1325 18Th St Nw #201 Washington, DC 20036

#1659 (202) 882-7878 Capitol City Dental Center 7723 Alaska Avenue, Nw Washington, DC 20012

#37679 (202) 582-0400 E G Harrison DMD 3230 Pennsylvania Ave Se, Suite230 Washington, DC 20020

#69560 (202) 829-2110 Eastern Family Dental 7826 Eastern Ave Nw, Ste 202 Washington, DC 20012

#61282 (202) 829-1266 Elizabeth Perry-Dodson DDS 7310 Alaska Ave Nw Washington, DC 20012

#139609 (202) 483-4237 Fred M Lee DDS 1824 Calvert St Nw, St Level Washington, DC 20009

#2739 (202) 333-0003 Georgetown Smile 4400 Macauthur Blvd, Ste 200 Washington, DC 20007

#2769 (202) 545-1998 Georgia Avenue Dental Clinic 7304 Georgia Ave Nw, Ste 2 Washington, DC 20012

#512* (202) 584-0710 Hillcrest Dental Assoc. 2811 Pennsylvania Ave, Ste 2 Washington, DC 20020

#50740 (202) 526-2902 Larry F McNair DDS 2033 Hamlin Street, Ne Washington, DC 20018

#281 (202) 872-1525 Michael G. Landy, D.D.S., F.A.G.D. 4600 Connecticut Ave Nw Washington, DC 20008

#51049 (202) 829-4319 Petworth Dental PLLC 800 Butternut St Nw Washington, DC 20012

#51048 (202) 829-4319 Petworth Dental PLLC 4018 Georgia Ave Nw Washington, DC 20011

#37585 (202) 393-8844 Prosthetic and TMJ Management 1800 I St, Ste 801 Washington, DC 20006

#1406 (202) 562-6340 Roy Baptiste DDS 3130 Mlk Ave, Se Washington, DC 20032

#1691 (202) 462-5227 Sharmin Dental Clinic/Rahim Sharmin, D.D.S. 1613 Harvard Street, Nw, Ste 108 Washington, DC 20009

#338 (202) 547-2674 Shelton R Penn DDS 5 Barney Cir Se Washington, DC 20003

#50966 (202) 234-8998 Smile Dental PC 2108 18Th St Nw, Ste 1 Washington, DC 20009

#273 (202) 785-9474 Yousefi Washington Clinic 3 Washington Cir, Ste G Washington, DC 20037

MArylAnDAlleGAny countycumberland

#454 (301) 722-6689 Frank A LaParle DDS PA 500 Memorial Ave., #401 Cumberland, MD 21502

lavale

#429* (301) 729-0444 Lynne S. Brodell, D.D.S. 12600 Winchester Rd #103 Lavale, MD 21502

Anne ArunDel countycrofton

#479 (410) 721-8200 Ulery Dental & Orthodontics 1286 Md Rt. 3 S, Ste 7 Crofton, MD 21114

Gambrills

#2216 (410) 672-3456 Gambrills Family Dentistry 959 Annapolis Rd Gambrills, MD 21054

Glen Burnie

#17299 (410) 768-8220 Jacques P Exposito DDS 1404 Crain Hwy S, Ste 110 Glen Burnie, MD 21061

#50372 (410) 859-1255 Ulery Dental and Orthodontics 7067 Baltimore Annapolis Blvd Glen Burnie, MD 21061

laurel

#284* (301) 725-7000 George M. Stephens, D.D.S. 3450 Ft. Meade Rd, Ste 211 Laurel, MD 20724

#446* (301) 498-6554 Saideh Tehrani, D.M.D. 3450 Fort Meade Rd #202, Ste 202 Laurel, MD 20724



Pasadena

#2011 (410) 590-6690 Ulery Dental & Orthodontics 8055 Ritchie Hwy, Ste 102 Pasadena, MD 21122

BAltiMore countyBaltimore

#17177 (410) 281-7700 Convenient Dental 1726 N Rolling Rd Baltimore, MD 21244

#61388* (410) 944-6666 Dental One Associates Security Blvd LLC 6666 Security Blvd Baltimore, MD 21207

#163 (410) 542-7877 Joseph L. Dyson, Jr., D.D.S. 4901 Liberty Heights Ave Baltimore, MD 21207

#2690 (410) 242-5012 Lansdowne Family Dental 2717 Hammonds Ferry Rd Baltimore, MD 21227

#291 (410) 256-9570 Maury J. Fechter, D.D.S. 8817 Belair Road, Ste 105 Baltimore, MD 21236

#11212 (410) 686-4646 Ned S Greenberg DDS PA 2100 Eastern Blvd Baltimore, MD 21220

#356 (410) 882-9330 Robert Kodeck, D.D.S. 7850 Rossville Blvd Baltimore, MD 21236

#271 (410) 668-4821 S.V. Ramamurthy, D.D.S. 8713 Harford Rd Baltimore, MD 21234

catonsville

#409 (410) 566-1550 Bruce E.Yuille, D.D.S. 700 Geipe Rd, Ste 270 Catonsville, MD 21228

#396 (410) 747-2566 The Dental Care Center 4 E Rolling Crossroads, Ste 104 Catonsville, MD 21228

Middle river

#51041 (410) 686-6510 Thomas G Tzomides DDS LLC 30 Middle River Rd Middle River, MD 21220

owings Mills

#51086 (410) 356-1400 Brian C Moore DMD PC 10085 Red Run Blvd, Ste 407 Owings Mills, MD 21117

#562* (410) 363-2269 Cynthia F. Miller, D.D.S. 6 Park Center Ct, Ste 107 Owings Mills, MD 21117

#302 (410) 363-1330 Jules Millman, D.D.S. 10353 Reisterstown Rd Owings Mills, MD 21117

Pikesville

#767 (410) 602-0295 Ogden M. Belt, D.D.S. The Commerce Center, 1777 Reisterstown Rd., #220 Pikesville, MD 21208

randallstown

#37724 (410) 655-7774 Esquire Family Dental Care, LLC 3673 Offutt Rd Randallstown, MD 21133

#9719 (410) 922-8088 Pleet And Freundlich DDS Pa 5310 Old Ct Rd, 202 Randallstown, MD 21133

towson

#51098 (410) 823-7910 Charles P McCausland III DDS 312 W Chesapeake Ave Towson, MD 21204

#529 (410) 823-1413 Joppa Partners 219 W Joppa Rd Towson, MD 21204

BAltiMore cityBaltimore

#1382 (410) 669-0700 Bell & Associates 3326 Auchentoroly Terr Baltimore, MD 21217

#68516 (410) 664-1900 Ernest J Colvin & Associates 4413 1/2 Park Heights Ave Baltimore, MD 21215

#68517 (410) 433-1991 Ernest J Colvin & Associates 5808 York Rd, Ste A Baltimore, MD 21212

#18764 (410) 362-2910 Fabian F Desbordes DDS 2300 Garrison Blvd, Ste 250 Baltimore, MD 21216

#164 (410) 542-7877 Joseph L. Dyson, Jr., D.D.S. 1721 Pennsylvania Ave Baltimore, MD 21217

#37648 (410) 325-7434 Margaret Kromah, D.D.S. 4403 Moravia Rd, Ste 2 Baltimore, MD 21206

#37616 (410) 426-1098 Maury J. Fechter, D.D.S. 6305 Bel Air Rd Baltimore, MD 21206

#37575 (410) 542-7800 Park West Health Systems 3319 W Belvedere Ave Baltimore, MD 21215

#1207 (410) 358-7646 Rena K. Langermann, DDS 6606 Cross Country Blvd Baltimore, MD 21215

#25390 (410) 372-0766 Robert A Goodman DDS 6301 N Charles St, Ste 3 Baltimore, MD 21212

#294* (410) 685-2850 Stephen B. Mastella, D.M.D. & Assoc, PA 1030 N Charles St, Ste 302 Baltimore, MD 21201

#69564 (410) 426-6072 Stephen J Hickey DMD 5010 Harford Rd Baltimore, MD 21214

#368 (410) 563-1976 Vivencio R. Reyes, D.D.S., P.A. 402 S Highland Ave Baltimore, MD 21224

cArroll countyFinksburg

#68507 (443) 293-7561 Earl M Addicks DDS PC 2025 Suffolk Rd, Ste 12 Finksburg, MD 21048

cecil countyelkton

#70916 (410) 398-7711 Delmarva Center for Dental Excellence 230 S Bridge St, Ste A Elkton, MD 21921

#2757 (410) 620-7055 Vargha Abbasian, D.D.S., P.C. 1653 Elkton Rd Elkton, MD 21921

cHArleS countyla Plata

#410* (301) 932-6133 Metro Dental Center 6620 Crain Hwy #204 La Plata, MD 20646

Waldorf

#72092 (301) 705-7197 Aegis Dental Group LLC 363 Smallwood Dr Waldorf, MD 20602

#70937 (301) 645-1110 Dimitri Dental 149 Smallwood Village Center Waldorf, MD 20602

#434 (301) 705-7552 Post Office Lake Dental Assoc. 603 Post Office Rd, Ste 208 Waldorf, MD 20602

#2324 (301) 374-9033 Tuan D Pham DMD & Joseph A Maloney DDS LLC 3450 Old Washington Rd, Ste 204 Waldorf, MD 20602

FreDerick countyFrederick

#37595 (301) 695-1414 Bright Now Dental 5726 B. Buckeystown Pk Frederick, MD 21704

#193 (301) 620-9090 Bright Now Dental 68 Thomas Johnson Dr, Ste B Frederick, MD 21702

#69530 (301) 644-8006 Deep Muko DDS PA 198 Thomas Johnson Dr, Ste 18 Frederick, MD 21702

HArForD countyAberdeen

#141139 (410) 272-2636 Alpha Dental Excellence 122 N Philadelphia Blvd Aberdeen, MD 21001

Bel Air

#2857 (410) 838-4404 Iwona Kubiczek, D.D.S., P.C. 2021-B Emmorton Rd, Ste 216 Bel Air, MD 21015

HoWArD countyelkridge

#2723 (410) 799-7172 Chartwell Dental Group 8180 Lark Brown Rd, Ste 202 Elkridge, MD 21075

#19200* (410) 796-7077 Robert E Skillman, D.D.S., PA 5921 Old Washington Rd Elkridge, MD 21075

ellicott city

#22440 (410) 480-3700 Ajmal Dental Care 10306 B Baltimore National Pik Ellicott City, MD 21042

#37537 (410) 465-3021 Ali R. Sedighian, D.D.S., P.A. 9005 Chevrolet Dr, Ste 1 Ellicott City, MD 21042

#70463 (410) 465-6262 Family Dentistry 9005 Chevrolet Dr, Ste 3 Ellicott City, MD 21042

#69942 (410) 730-0043 Sinha Kang DMD 5034 Dorsey Hall Dr, Ste 203 Ellicott City, MD 21042

Woodstock

#69952 (410) 750-7855 Dr Bluchers Family Dentistry 10741 Birmingham Way Woodstock, MD 21163

MontGoMery countyBethesda

#2367 (301) 469-4775 Amisha N. Shroff, D.D.S., P.C. 10320 Westlake Dr, Ste 109 Bethesda, MD 20817

#50668 (301) 365-0055 M Reza Shefaat DDS 7501 Democracy Blvd, Ste 121 Bethesda, MD 20817

#50850 (301) 652-3888 Peter S DeMizio DDS Inc 4400 E W Hwy, Ste D Bethesda, MD 20814

#460* (301) 718-3656 Reginald W Cole, DDS 4400 East-West Hwy Ste F Bethesda, MD 20814

#1405 (301) 913-0056 Roanne Wiczer DMD 8311 Wisconsin Ave, Ste B8 Bethesda, MD 20814

Burtonsville

#37698 (301) 476-8330 Mon F. Sheik, DMD 15324 Spencerville Ct, 101 Burtonsville, MD 20866

Gaithersburg

#33884 (301) 990-3697 Angamuthu & Associates DDS PA 4 Professional Dr, Ste 121 Gaithersburg, MD 20879

#4589 (301) 926-6622 Arnold I Malhmood DDS 474 N Frederick Ave Gaithersburg, MD 20877

#50592 (301) 977-8100 Chestnut Street Cosmetic Dentistry 101 Chestnut St, Ste 130 Gaithersburg, MD 20877

#2432 (301) 977-3766 Gerry Dubin, DMD, P.C. 9069 Shady Grove Ct Gaithersburg, MD 20877

#463 (301) 963-0665 The Dental Suite 18218 Flower Hill Way Gaithersburg, MD 20879

#2854 (301) 208-0002 TLC Modern Dentistry 18220 Contour Rd Gaithersburg, MD 20877

Germantown

#4687 (301) 515-0030 Family Dental Care 19729 Executive Park Cir Germantown, MD 20874

#137482 (240) 246-7900 Oasis Dental Clinic LLC 19533 Doctors Dr Germantown, MD 20874



#37733 (301) 528-5490 Peter S. DeMizio, DDS, Inc. 22 Executive Park Ct Germantown, MD 20874

#50893* (301) 528-6633 Smile Design Dental 19735 Germantown Rd, Ste 170 Germantown, MD 20874

kensington

#14880 (301) 946-5600 Robert Barnett DDS 3720 Farragut Ave, Ste 101 Kensington, MD 20895

olney

#50918 (301) 260-0949 Premier Dental Clinic 17904 Georgia Ave, Ste 110 Olney, MD 20832

rockville

#33849 (301) 424-7150 AA Dental Clinic 751 Rockville Pk, Ste 10A Rockville, MD 20852

#2745* (301) 231-0173 Chetan H. Parikh, D.M.D., PA 5808 Hubbard Dr Rockville, MD 20852

#50814 (301) 881-3368 Happy Dental 4701 Randolph Rd, Ste 210 Rockville, MD 20852

#1041* (301) 340-2309 Hysosik Kim, D.D.S. 785-A Rockville Pk Rockville, MD 20852

#97861 (301) 838-9300 Key West Dental Care 9850 Keywest Ave, Ste 302 Rockville, MD 20850

#37655* (301) 926-4408 North Potomac Smiles LLC 15200 Shady Grove Rd, Ste 408 Rockville, MD 20850

#37731 (301) 770-3929 Rockville Family Dental Group 5806 Hubbard Dr Rockville, MD 20852

Silver Spring

#37792 (301) 438-2003 Aegis Dental Group 14440 Layhill Rd Silver Spring, MD 20906

#51014† (301) 445-4888 Asma Nuh DDS PA 1016 Merrimac Dr Silver Spring, MD 20903

#8779 (301) 460-1212 Aspen Hill General And Cosmetic Dentistry 13975 Connecticut Ave, Ste 200 Silver Spring, MD 20906

#1753 (301) 593-0060 Hedyeh Atashbar, D.D.S. 11213 Lockwood Dr Silver Spring, MD 20901

#844 (301) 589-1143 Negin A. Moazami, D.D.S. 8630 Fenton St, Ste 902 Silver Spring, MD 20910

#51079 (301) 384-6600 Silver Spring Dental Care LLC 13321 New Hampshire Ave, Ste 201 Silver Spring, MD 20904

#50327 (301) 933-1401 TLC Modern Dentistry LLC 13623 H-I Georgia Ave Silver Spring, MD 20906

takoma Park

#282 (301) 270-4023 Warner Family Dental Center 7000 Carroll Ave Takoma Park, MD 20912

#692 (301) 891-2300 William E. Vaughan, D.D.S. 7600 Maple Ave Ste 6 Takoma Park, MD 20912

Wheaton

#192* (301) 942-5500 Sterling Dental Centers 12114 Georgia Ave Wheaton, MD 20902

Prince GeorGeS countyBowie

#68505 (301) 262-1112 Kemmerton Family Dentistry 6000 Laurel-Bowie Rd, Ste 101 Bowie, MD 20715

#332 (301) 249-1841 Neville McKen, D.D.S. 3060 Mitchellville Rd, Ste 213 Bowie, MD 20715

#14419 (301) 262-0800 Tanzania Davis DDS 3231 Superior Ln, Ste A 22 Bowie, MD 20715

capitol Heights

#161 (301) 333-5882 Gentle Dental Care / Dr. Vincent Davis 9146 Edgeworth Dr Capitol Heights, MD 20743

#333 (301) 336-7535 Neville McKen, D.D.S. 9171 Central Ave, Ste L9 Capitol Heights, MD 20743

clinton

#2862 (301) 868-8659 Alpha Dental Care LLC 8975 Woodyard Rd Clinton, MD 20735

#37717 (301) 877-1622 Alvin B Williams DDS 9135 Piscataway Rd, #105 Clinton, MD 20735

#735* (301) 868-6703 Joseph A. Maloney, D.D.S. 9131 Piscataway Rd, Ste 739 Clinton, MD 20735

college Park

#37542 (301) 927-2500 College Park Dental 7305 Baltimore Ave, #204 College Park, MD 20740

#346 (301) 927-9011 Daniel J. Lane, D.D.S. 7307 Baltimore Ave, Ste 113 College Park, MD 20740

Forestville

#72091 (301) 735-5137 Warner Dental Care LLC 7610 Pennsylvania Ave, Ste 302 Forestville, MD 20747

Fort Washington

#50328 (240) 253-1965 All Smiles Dental Care 12803 Old Fort Rd, Ste 203 Fort Washington, MD 20744

#334* (301) 567-1992 Neville McKen DDS 8602 Dover St Fort Washington, MD 20744

#330 (301) 203-7035 Pamela V. Hymes, D.D.S., PA 10905 Fort Washington Rd, Ste 203 Fort Washington, MD 20744

Greenbelt

#1187 (301) 345-8600 Greenbelt Dental Care, P.C. 7525 Greenway Center Dr, Ste 201 Greenbelt, MD 20770

Hyattsville

#51085 (301) 559-1659 Brian C Moore DMD PC 3311 Toledo Terr, Ste C102 Hyattsville, MD 20782

#960* (301) 577-6333 Daniel De Haas, D.D.S. 7101 Annapolis Rd Hyattsville, MD 20784

#407 (301) 927-1616 Friendship Dental 6525 Belcrest Rd, Ste 208 Hyattsville, MD 20782

#2370 (301) 386-3533 Hall and Associates 7221 E Ridge Dr Hyattsville, MD 20785

#2523 (301) 434-3300 Tajicks Dental Clinic 7411 Riggs Rd, #108 Hyattsville, MD 20783

landover Hills

#191* (301) 577-2610 Sterling Dental Centers 7503 A Annapolis Rd Landover Hills, MD 20784

largo

#186 (301) 773-4177 Harry J. Klapper, D.D.S. 1300 Mercantile Ln, Ste 100E Largo, MD 20774

#1270 (301) 341-2131 Yardee Dental/ Dr. Jemi Sanusi 1400 Mercantile Ln Ste.224 Largo, MD 20774

laurel

#1053 (301) 953-3021 Drs. Batz and Weiner Lake Dental 8363 Cherry Ln Laurel, MD 20707

#1199 (301) 604-8117 John N. Kim, D.D.S., P.A. 8301 Cherry Ln Laurel, MD 20707

#2118 (301) 623-3737 Ulery Dental & Orthodontics 12793 Laurel Bowie Rd Laurel, MD 20708

oxon Hill

#324 (301) 567-3122 David G. O’Neal, D.D.S., & Assoc. 6188 Oxon Hill Rd, Ste 200 Oxon Hill, MD 20745

#37629 (301) 505-6055 Quentin E Monroe Dental Services 5448 St Barnabas Rd Oxon Hill, MD 20745

riverdale

#210*† (301) 864-5200 The Dental Group 6200 Baltimore Ave, Ste 200 Riverdale, MD 20737

#210* (301) 864-5200 The Dental Group 6200 Baltimore Ave, Ste 200 Riverdale, MD 20737

Suitland

#16470 (301) 568-8991 Suitland Dental Center 4814 Silver Hill Rd Suitland, MD 20746

temple Hills

#37663 (301) 702-4080 All Smiles Dental Care 3847 Branch Ave, Ste 124 Temple Hills, MD 20748

#137478 (301) 326-3409 Christian Dental Care 3611 Branch Ave, Ste 301 Temple Hills, MD 20748

#79801 (301) 449-2800 Dental Associates of Greater MD at Temple Hills 6339 Allentown Rd, Ste E Temple Hills, MD 20748

#51072 (301) 423-6423 Oral Health Associates 4316 St Barnabas Rd Temple Hills, MD 20748

upper Marlboro

#187 (301) 627-1414 Harry J. Klapper, D.D.S. 5749 Crain Hwy Upper Marlboro, MD 20772

WASHinGton countyHagerstown

#462 (301) 797-7078 Antietam Valley Dental Center 1246 Maryland Ave Hagerstown, MD 21740

Hancock

#68461 (301) 678-6788 Antietam Valley Dental Center 257 W Main St Hancock, MD 21750

WicoMico countySalisbury

#2767 (410) 546-5900 Delaware Maryland Dental 123 W College Ave Salisbury, MD 21804

#2319 (410) 742-0166 George C Viertl DDS PC 560 Riverside Dr, Ste B206 Salisbury, MD 21801

WorceSter countyocean Pines

#33847 (410) 208-0054 Robert D Steinberg DDS 11204 Racetrack Rd, Pavillions Ste 102 Ocean Pines, MD 21811

Premium Dollar Distribution

Dominion is licensed as a Dental Plan Organization (DPO) in the State of Maryland. Providers are paid through a combination of member copayments and capitation dollars (predetermined monthly payments per member).

This chart shows how premium dollars were distributed in 2012 between dentist compensation and administration costs.

The following explanation as required by the Maryland Insurance Administration.









71%

26%3%

Dentist Compensation

Administration Costs

Other

71%

26%3%



Other

71%

26%3%



Other

Documents

Select Plan1 709s - fop89.org · PDF fileQuarter 2012. Mid-Atlantic includes D.C., ... D6545 Retainer - cast metal for resin bonded fixed prosthesis ... , three or more surfaces