Customer Service Inquiry

The administering Delta Dental member company for the state of KS is: Delta Dental of Kansas
	Customer Service Phone Number(s):    800-234-3375    316-264-4511 FAX:    316-462-3392 E-mail:    moreinfo@deltadentalks.com Mailing Address:    P.O. Box 789769    Wichita,  KS  67278-9769

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 (*).

Note: Please do not include protected health information when using this form.

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:  -   -