Allen Lee,-Waltham-General Dentistry

info@dentalvisits.com

General Dentistry

0 Year(s) Experience

Details: Business Name:

Category:

Full Name:

Address:

City:

State:

Country:

Zip/Postal Code

Book Appointment
Credentials: Education:

Awards & Distinctions:

Affilations:
Location & Availability: , , , , (Day Phone)
In-network Insurances Accepted: Acceptance of particular insurance plans may vary, based on different office locations. As a result, we've listed plans accepted at different locations.

No Insurance found!
Leave A Review: Leave a Comment

Dr. Butcher House

,

Patients

Are your Looking For Dental Care?

Patients experience different levels of care, that's why Dentalvisits is the best place to find dental care.

Registration

Doctor

Are your Looking For New Patients?

Dentalvisits is the best way to see new patients and build your practice.

Registration

Doctor

Save time & money

Save upto 70% in time and money spent for consultation

Registration

Your Full Name	Your Email	Your Mobile Number
Gender	Address	Address2
City	State	Country
Emergency Contact Name	Emergency Contact Phone	Home Phone
Mother FirstName	Mother LastName	Wireless Phone
Work Phone	Date Of Birth

1) INSURANCE INFORMATION
                                                    Insurance Company : 
                                                    
                                                    Address : 
                                                    
                                                    Phone Number : 
                                                    
                                                    Employer : 
                                                    
                                                    Group Number : 
                                                    
                                                    Effective Date : 
                                                    
                                                    Renewal Month : 
                                                    
                                                    Yearly Maximum  : 
                                                    
                                                    Deductible Per Individual $ : 
                                                    
                                                    Deductible Per Family $ : 
                                                    
This deductible applies to : 
                                                        
                                                        Preventative
                                                    
                                                        Basic
                                                    
                                                        Major
                                                    
 2) INSURANCE INFORMATION 
                                                    Insurance Company : 
                                                    
                                                    Address : 
                                                    
                                                    Phone Number : 
                                                    
                                                    Employer : 
                                                    
                                                    Group Number : 
                                                    
                                                    Effective Date : 
                                                    
                                                    Renewal Month : 
                                                    
                                                    Yearly Maximum  : 
                                                    
                                                    Deductible Per Individual $ : 
                                                    
                                                    Deductible Per Family $ : 
                                                    
This deductible applies to : 
                                                        
                                                        Preventative
                                                    
                                                        Basic
                                                    
                                                        Major
                                                    
PREVENTATIVE COVERAGE
                                                    Covered at : 
                                                     %
                                                
Is there a waiting period for preventative coverage? : 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    Effective Date : 
                                                    
                                                    Prophylaxis/Exam Frequency : 
                                                    
                                                    Bitewing Frequency : 
                                                    
                                                    Eligible for an FMS every : 
                                                    
                                                     Last FMS : 
                                                    
 Eligible for an FMS now? : 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                     Fluoride Varnish (D1203/D1204/D1206) Frequency : 
                                                    
 there an age limit on fluoride varnish applications? : 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                      If yes, at age : 
                                                    
Is there sealant (D1351) coverage? : 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
Teeth covered : 
                                                        
                                                        Molars
                                                    
                                                        Premolar
                                                    
Is there an age limit on sealants?: 
                                                        
                                                        Molars
                                                    
                                                        Premolar
                                                    
                                                      If yes, at age : 
                                                    
                                                    Replacement on sealants is : 
                                                    
BASIC COVERAGE
                                                    Covered at : 
                                                     %
                                                
 Is there a waiting period for basic coverage? :  
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                     Effective Date : 
                                                    
                                                    Includes : 
                                                    
MAJOR COVERAGE
                                                    Covered at : 
                                                     %
                                                
 Is there a waiting period for major coverage? : 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                     Effective Date : 
                                                    
                                                    Includes : 
                                                    
PERIODONTAL COVERAGEDoes the patient have any history of SRP (D4341/D4342)? : 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                     If yes, when?: 
                                                    
Is SRP (D4341/D4342) covered?: 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    Frequency: 
                                                    
Can SRP (D4341/D4342) be performed on all quadrants at the same visit? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    If not, what is the waiting period? 
                                                    
Can an adult prophylaxis and isolated SRP (D4342) be done at the same visit? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                     If not, what is the waiting period? 
                                                    
Is periodontal maintenance (D4910) covered? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    Frequency: 
                                                    
IMPLANT COVERAGEAre endosteal implants (D6012) covered? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                     If yes, when?: 
                                                     %
                                                
Are bone replacement grafts (D7953) covered? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    If yes, covered at 
                                                     %
                                                
Are guided-tissue regeneration barriers (D4266/D4267) covered? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    If yes, covered at 
                                                     %
                                                
Are implant abutments (D6056/D6057) covered? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    If yes, covered at 
                                                     %
                                                
Are implant crowns (D6065/D6066/D6067) covered? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    If yes, covered at 
                                                     %
                                                
Is a pre-determination required prior to implant surgery? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
ORTHODONTIC COVERAGEAre orthodontics covered? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    If yes, covered at 
                                                     %
                                                
Is there an age limit on orthodontic coverage? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    If yes, at age 
                                                    
Is there a lifetime maximum? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                     If yes, the lifetime maximum is 
                                                    
MISCELLANEOUSAre nightguards (D9940) covered? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    If yes, covered at 
                                                     %
                                                
Is nitrous oxide (D9230) covered? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
                                                    If yes, at age 
                                                    
Replacement on crowns and bridges is: 
                                                         year
                                                    
Replacement on complete and partial dentures is: 
                                                         year
                                                    
Are prior extractions covered (missing tooth clause)? 
                                                        
                                                        Yes
                                                    
                                                        No
                                                    
ADDITIONAL NOTES
                                            
                                        Payment for services rendered is due at the time of each appointment. Please call us if you have any questions at 212-697-0939
                                    
                                            For office use only:
                                            
                                            Employee name and number:

                                        Date:

We texted you a verification code. For security reasons,the code expires in 10 minutes.

Code Numbers
* Please enter the 10-digit code that you received. If you didn`t get a code please try again
Code is correct Code is Wrong

Copyrights ©2021 : Copyright by Dentalvisits. All Rights Reserved.