Two Great Dental Programsapproximately 30,000 participating dentist locations in California. Viken...

17871 Park Plaza Drive, Suite 200Cerritos, CA 90703

KPIC’s dental program information: 800-933-9312DeltaCare USA information: 800-422-4234

E (rev. 9/10) #59331 KA5 SA-01-904-05

Administered by

Two Great Dental Programs

For 2011 Kaiser Permanente Federal MembersYou must be enrolled in the Kaiser Permanente medical plan to elect dental coverage

Kaiser Permanente is pleased to offer Federal employees and eligible Federal retirees and dependents who are currently enrolled or planning to enroll in Kaiser Permanente’s Traditional HMO plan a choice of the dental plans described below. Option 1 is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., and is administered by Delta Dental of California (Delta Dental). Option 2 is a DeltaCare® USA Dental Health Care program provided by Delta Dental of California. These benefits are neither offered nor guaranteed under a contract with the Federal Employees Health Benefit (FEHB) Program, but are made available to all enrollees and family members who become members of Kaiser Permanente.

During the annual open season period, you have the opportunity to enroll in one of the two plans. If you are already enrolled, you may change plans during this period. Your coverage under the enrolled plan will become effective on January 1, 2011 and will extend through December 31, 2011, subject to your continued premium payments and enrollment in Kaiser Permanente’s Traditional HMO Plan. If you are already enrolled under one of the two dental plans and are not planning on changing your coverage, you do not need to complete the enrollment form. If you are changing plans, you must provide 30-days advance written notice of termination. If you are covered under Option 1, the notice must be sent to Delta Dental (see page 7 for address). If you are covered under Option 2, the notice must be sent to DeltaCare USA (see page 18 for address).

You have two dental plans to choose from:

2 DeltaCare USA is a dental HMO program, administered by Delta Dental. With DeltaCare USA, you select a conveniently located network dentist to provide dental care for you and

your family. A list of participating network dentists is enclosed for your review. Depending on the service you receive, you pay either a small copayment or no copayment at all. With the DeltaCare USA program, there are no deductibles and no claim forms.

1KPIC’s Group Dental Insurance Plan allows you the freedom to see any licensed dentist of your choice. It uses a Table of Allowances that lists the dollar

amount KPIC will pay for each covered dental service. A copy of the Table of Allowances is included in this brochure.

Remember that you are enrolling in your selected dental plan for a period of one year. This does not apply if your employment is terminated. Payment for either the KPIC or Delta Dental plan will be automatically withdrawn from the checking, savings or credit union account you specify. To review a brochure of the program, visit kp.org/feds.

For questions about KPIC’s Dental Insurance Plan, contact Delta Dental at: 888-335-8227 - Monday through FridayYour Kaiser Federal group number is #9874 8 a.m. - 4 p.m. Pacific time

For questions about DeltaCare USA, contact Delta Dental at: 800-422-4234 - Monday through FridayYour Kaiser Federal group number is #1114 5 a.m. - 6 p.m. Pacific time

Monthly KPIC Premium* Dental Insurance Plan

Self Only $29.03 Self & One Party $51.44 Self & Two or More $77.32

*Good through December 31, 2011

With KPIC's Group Dental Insurance Plan . . . With DeltaCare USA . . . • You have the freedom to choose any licensed dentist.

• Each family member may visit a different dentist.

• Table of Allowances lists the specific dollar amountpayable for each covered dental service.

• Orthodontic services are not covered.

• Claims paperwork is handled for you when you see one of Delta Dental’s approximately 30,000 participating dentist locations in California.

• There is a deductible of $50 per person ($150 maximum per family); the maximum the program covers annually is $1,000 per person.

• There is no deductible for diagnostic and preventive services.

• Some procedures are subject to waiting periods

• You select one of the more than 6,200 network dentists statewide.

• General dental care for the entire family is provided by a network dentist.

• You pay a modest or no copayment for covered services.

• Orthodontic services with a copayment of $1,600 for children under 19 and $1,800 for covered adults and dependent adult children.

• There are no claim forms to complete.

• There are no deductibles.

• There are no annual maximums except for accidental injury.

DeltaCare USA Monthly* Quarterly* Self Only $ 11.89 $ 35.67 Self & One Party $ 19.90 $ 59.70 Self & Two or More $ 30.17 $ 90.51


See Green Section Beginning on Page 1 See Blue Section Beginning on Page 9

37

YUCAIPAImperial Dental Practice #00092534880 Yucaipa Blvd 909-797-1136 F/T 1 P/T 1 (SP)Yucaipa Family Dentistry #15760134488 Yucaipa Blvd Ste F 909-797-0303 F/T 1 (GE, JA, KO, SP, RO)YUCCA VALLEYY. Chang, DDS #0116317024 Airway Ave Ste A 760-365-2351 F/T 1 (KO, SP)

ALISO VIEJORobert Murray, DDS #271701949-831-4655 P/T 1 (KO, SP, TA, VI) U

ANAHEIMDrs Anthony and Naomi Wong #256401714-995-3051 F/T 1 P/T 1 (CA, CH)F Foroutan, DDS Inc #000219714-693-1889 F/T 1 (PE, SP)Nandini Murthy, DDS #183601714-774-2638 P/T 1 (SP, HI)ARCADIABingzhong Fang, DMD #007863626-254-9066 F/T 1 (CH)BAKERSFIELDJavier Central Valley Dental #018808661-323-0076 F/T 1 (SP, TA) U

Kenneth Krauss, DDS #131001661-323-8585 F/T 1Premier Family Dentistry #020862661-324-1200 F/T 1 (KO, SP)BALDWIN PARKLuis Alvarado, DDS #025183626-856-3456 F/T 2 (SP)BELLFLOWERBenjamin Woo, DDS #354901562-925-3715 F/T 1 (CH, SP, TA)BEVERLY HILLSLilia Agadganian, DDS Inc #012471310-652-8877 F/T 1 (AM, RU, SP) U

CARLSBADAvia Dental Care #033158760-431-7711 F/T 1COMPTONQureshi Compton Fmly Dtl #2C6401310-639-5330 F/T 1 (SP)Shailesh Parikh, Dds #038101310-639-7970 F/T 1 (Sp)CULVER CITYCulver City Family Dental Ctr #018123310-642-5999 F/T 1 (SP) U

Gary Wirtschafter, DDS #374401310-839-8033 F/T 1 (FR, SP) U

Steven Seldon, DDS #381601310-204-0700 F/T 1Warren Kaufman, DDS #041701310-838-7780 F/T 2 P/T 1 (SP)

CYPRESSSamuel Au, DDS #012688714-826-9988 F/T 1 (CH, KO) U

DOWNEYRichard Lee, DDS #019414562-622-1948 F/T 1 (SP) U

Wilk Peery, DDS Inc #023828562-862-4543 F/T 1 (Sp)DUARTESaleh Kholaki, DDS #366801626-301-4220 F/T 1 (AR, SP)ENCINOFirouzeh Banki, DDS #3C0301818-990-5900 F/T 1 P/T 1 (SP) U

FOUNTAIN VALLEYPaul Jaruszewski, DDS #260701714-963-3005 F/T 1 (SP) U

FULLERTONFamily Dental #174601714-525-4538 F/T 1 (AR, SP, HI) U

GARDEN GROVEBristol Dental Group #353101714-638-9999 F/T 1 (SP) U

GLENDORASan Dimas Dental Group #023401626-857-4702 F/T 2 P/T 1 U

GRANADA HILLSFamily Dentistry #000632818-832-2087 F/T 1 (SP, TA)HACIENDA HEIGHTSRonald Nichols, DDS #324801626-912-9394 F/T 1 (SP) U

HAWTHORNEBurton Schnierow, DDS #286801310-679-0106 F/T 4 (AR, CH, FR, SP, TA) U

Santa Maria Dental Ofc #003889310-973-0945 F/T 1 (SP)HEMETSmile Shop #017951951-306-0987 F/T 1 (SP) U

HESPERIAL Mowery, DDS Inc #360701760-244-5047 F/T 1 P/T 1 (SP) U

HUNTINGTON BEACHArthur Cabrera, DDS #305601714-965-6025 F/T 1 (SP) U

Gabriel Capdevila, DDS #151801714-846-2895 F/T 1 (SP)INDIAN WELLSClark Cressman, DDS #006624760-836-0052 P/T 1 (SP)IRVINEGrace Han, DMD #021494949-502-6406 F/T 1 (KO, SP) U

LA HABRAHarbor Dental #1C2401562-690-3551 P/T 1 (CH, SP) U

Juliet Chua, DDS #355701562-691-7438 F/T 1 (CH, SP, TA) U

LA MESASmilehaven Dental Center #358801619-464-2801 P/T 1 (TA)LADERA RANCHSerene Family Dentistry #032353949-218-4000 F/T 1 (PE, SP) U

LONG BEACHDr Willard Hankins Jr #026087562-421-8206 F/T 1 (SP)LOS ANGELESArturo Ibarra, DDS #003990323-260-7173 F/T 1 (SP)Arturo Ibarra, DDS #003991323-221-3165 F/T 1 (SP)Belinda Balais, DMD #002777213-229-0005 F/T 1 (SP, TA)Culver City Mar Vista Dental #012166310-398-6161 P/T 1 (HE, PE, SP)George Tay Family Dentistry #000634323-227-9885 F/T 1 (CH, SP) U

RK Chetty DDS Inc #041801323-258-2885 F/T 2 (SP, HI) U

Shaw Adams Dental Group #092401323-933-5641 F/T 1 (SP)MISSION VIEJOMontgomery & Kiriak DDS #3C0601949-347-0807 F/T 1 P/T 1 (GE, SP)MORENO VALLEYWilliam Kohl, DDS #202601951-924-9831 F/T 1NATIONAL CITYCivic Center Dental Group #321901619-474-6200 F/T 1 (SP, TA)NORTH HOLLYWOODAlan Brody, DDS #209401818-762-2682 F/T 1 (SP, GR, HI) U

NORTHRIDGEAll Family Dental Care #3C7201818-709-9988 F/T 1 (SP)Raffi Najarian, DDS #008628818-363-7469 P/T 1 (AM, SP)NORWALKRalph Nicassio, DDS #283601562-868-7768 F/T 2 (SP) U

OCEANSIDEOcean Ranch Dentistry #028067760-453-2900y F/T 2 (SP, VI) U

ORANGEOrange Dental Arts #029282714-538-2400 F/T 1PALMDALEC.I. Dentistry #026341661-947-2400 F/T 1 (SP) U

Y Siani, DMD #375601661-947-6782 F/T 1 (SP) U

PASO ROBLESDavid Krill, DDS #000940805-239-2146 F/T 2 (SP) U

RANCHO SANTA MARGARITA Platinum Dental #013496949-888-0806 F/T 2 U

REDLANDSJohn Cesario, DDS #002339909-798-7228 F/T 1

RIVERSIDEIndian Hills Dental #010408951-361-0443 F/T 1 (SP) U

Nat Shain, DDS #153101951-788-4500 F/T 1Vivian Kwon, DDS #172501951-689-8544 F/T 1 (KO, SP)Wei Min Tu, DDS Inc #021699951-343-1211y (CH, SP) U

ROWLAND HEIGHTSMichael Chan, DDS #372101626-913-0222 F/T 1 (CH, SP) U

SAN DIEGORancho Bernardo Town Ctr #023306858-451-2555 F/T 1 (SP, VI) U

SAN JUAN CAPISTRANOKirk Hobock, DDS #285601949-493-6006 F/T 1 (SP) U

SAN MARCOSMichael Nelson, DDS #268801760-471-9560 F/T 2SANTA ANAJason Sang Lee, DDS Inc #022068714-547-7379 F/T 1 U

SHERMAN OAKSGus Huerta, DDS #391701818-995-8484 F/T 1 (SP, RO) U

TOLUCA LAKENajarian And Najarian DDS #120301818-769-1111 F/T 1 (AM, PE)TORRANCESouth Bay Family Dental Group #340001310-539-5566 F/T 2 P/T 1 (AM, SP, HR)VAN NUYSCalifornia Smiles Dental Grp #021219818-908-9800 F/T 2 (AM, AR, PE, SP) U

WEST COVINAEdison Der, DDS #002401626-858-3305 F/T 1 U

Gerald V Garcia, DMD Inc #016879626-338-7092 P/T 1 (TA, SP)Gregory Robins Fmly Dnstry #383201626-919-7707 F/T 1 P/T 2 (GE, KO, FR, SP) U

Katherine Forbes, DDS #370401626-939-0639 F/T 1 (SP)WESTMINSTERBoyd Joyer Jr, DDS #357801714-893-2411 F/T 1 U

WOODLAND HILLSThomas Bartle, DMD #134301818-224-2095 F/T 1 (SP)Viken Toutounjian, DDS #395901818-348-3801 F/T 1 (AR, AM, RU) U

U — The wheelchair symbol indicates functional accessibility for individuals with limited mobility. Information regarding Dental office accessibility for patients with mobility impairments is available by calling Customer Service at 800-422-4234.

Visit us at our website: www.deltadentalins.com/deltacareusa. NOTE: The “01” listed at the end of each provider number shown is for internal use only. The provider selection will be honored whether OR NOT the “01” is noted on the enrollment form.Additional Dental Offices will be added as required. You may call the DeltaCare USA Customer Service department at 800-422-4234 for updates to the provider list. If any office is closed to further enrollment, Delta Dental reserves the right to assign you another dental office as close to your home as possible.

Southern CaliforniaClosed Offices

36 1

ABOUT KPIC’S DENTAL INSURANCE PLAN If you’re concerned about the cost of dental treatment for you

and your family, you should know about KPIC’s group dental insurance plan. With a low monthly premium, KPIC’s group dental insurance plan allows you to budget for your annual dental costs. You can do this because KPIC’s dental insurance plan contains a Table of Allowances listing the specific dollar amount KPIC will pay for each covered dental service. Since you receive in advance the complete Table of Allowances for the plan, you’ll know exactly how much of your treatment will be covered. Because dental fees do vary by dentist, it may be to your advantage to compare your dentist's fees prior to making an appointment.

WHO CAN JOIN As a Federal employee or a Federal retiree enrolled in Kaiser

Permanente’s traditional HMO Plan, you and your eligible dependents are eligible for coverage under KPIC’s group dental insurance plan. Your eligible dependents include your lawful spouse and unmarried children under 26 years old, including stepchildren and children placed with you for adoption or foster care. An unmarried child 26 years of age or older may continue to be eligible as a dependent if incapable of self-support because of physical handicap or mental retardation that commenced prior to age 26, provided that the person is legally residing with and dependent upon the eligible member, and Delta Dental receives notice of the disability.

FREE CHOICE OF DENTISTS Many dental plans restrict your choice of dentists to one

from a limited network. But with KPIC’s group dental insurance plan, you may go to any licensed dentist. You and your covered dependents may even choose to go to different dentists. To use KPIC’s group dental insurance plan, simply make an appointment with the dentist of your choice. When seeing a participating dentist, be sure to give the dental office your Kaiser Federal group number and social security number.

SPECIAL ADVANTAGES FROM DELTA DENTISTS KPIC’s group dental insurance plan is administered by Delta

Dental of California, and you get special advantages when you go to one of the more than 30,000 Delta Dental dentist locations in California. These participating dentists have agreed to handle all your claims paperwork and to charge you no more than the fees negotiated by Delta Dental. As KPIC’s administrator, Delta Dental reimburses these dentists directly, so you are responsible only for the amount of the charge that exceeds the covered amount shown in the Table of Allowances. If you go to a non-participating dentist (a dentist not participating with Delta Dental), you are responsible for the entire charge and must submit a claim to Delta Dental for reimbursement. Delta Dental will reimburse you directly for the amount shown in the Table of Allowances. Since approximately 93 percent of California’s dentists are Delta Dental dentists, your current dentist is probably already participating. Ask your dentist if he or she is a Delta Dental dentist.

One of your non-FEHB Dental plan options is a dental insurance plan underwritten by KPIC, and administered by Delta Dental of California.

KPIC’s group dental insurance plan uses a Table of Allowances and allows you the freedom to see any licensed dentist of your choice. The Table of Allowances lists the dollar amount KPIC will pay for each covered dental service. A copy of the Table of Allowances is shown on pages 4 and 5 of this brochure.

The monthly premiums for 2011 are listed below:

Monthly KPIC Premiums* Dental Insurance Plan Self Only $29.03 Self & One Party $51.44 Self & Two or More $77.32


NOTE: This is only a brief description of your coverage. A certificate of insurance and schedule of coverage setting forth the terms and conditions of your coverage will be sent to you after you enroll. The dental coverage described in this section of the brochure is underwritten by Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP).

These benefits are neither offered nor guaranteed under contract with the FEHB Program.

KPIC DENTAL INSURANCE PLANC Squared Dentistry #02480828212 K Johnson Pkwy Ste 180 661-702-0940 F/T 1 (CH, PE)Canyon Dental Group #01566628237 Newhall Ranch Rd 661-257-4242 P/T 1 (SP) U

Daniel Liberman, DDS #01724423501 Cinema Dr Ste 112 661-290-3355 F/T 1 (RU, SP, TA) U

David Abri, DDS #02316623333 Cinema Dr Ste 190 661-254-9494 P/T 1 U

George Koutsoukos, DDS #03072524155 Magic Mountain Pkwy 661-222-7724 F/T 1 (GR, SP) U

Nilda Woolard, DMD #00354223369 Lyons Ave 661-259-7702 F/T 1 (SP) U

Raymond Lotuaco, DDS #01954823501 Cinema Dr Ste 207 661-753-9456 F/T 1 (SP, TA) U

Valencia Dental Arts #00801727420 Tourney Rd Ste 230 661-799-9989 F/T 1 (SP) U

Valencia Dental Care #12170123838 Valencia Blvd Ste 301 661-291-1412 P/T 2 (SP, KO) U

Valencia Dental Group #00766324218 Valencia Blvd 661-288-0288 P/T 1 (SP)Valencia Dental Group #00766426938 Old Road Ste P 661-799-0886 F/T 1 P/T 1 (SP)Vista Village Dental Group #00021525864 Tournament Rd Ste F 661-259-5001 P/T 1 (SP) U

VALLEY VILLAGEAllen Zebrack, DDS #01358412840 Riverside Dr Ste 406 818-763-9701 F/T 1 (SP)Laurel Chandler Dental #3053014717 Laurel Cyn Blvd Ste 200 818-508-2250 F/T 1 P/T 1 (SP, TA) U

Samuel Hunanian, DDS #0217455953 Laurel Canyon Blvd # B 818-508-7200 F/T 1 (RU, AM)VAN NUYSAffordable Gentle Dental #0072766600-A Van Nuys Blvd 818-782-5020 F/T 1 P/T 1 (CH, SP) U

Family Dentistry 2 #02249015355 Sherman Way Ste K 818-997-7797 P/T 1 (SP) U

Global Dental Practice #02178214434 Hamlin St Ste 2 818-781-5180 F/T 1 (SP)Gohar Hovsepyan, DDS #00942915333 Sherman Way Ste M 818-909-0200 F/T 1 (AM, RU, SP) U

Golden Care Dentistry #0305826330 B Van Nuys Blvd 818-785-9944 P/T 1 (PE, SP)Hamlin Dental Group #00280114401 Hamlin St Ste D 818-782-6919 F/T 1 P/T 2 (AR, TA, AM, PE, SP)Joseph Hakimi, DDS #0195526624 Van Nuys Blvd 818-909-9291 F/T 1 (PE, SP) U

Lourdes Alejandro, DDS #02427916221 Victory Blvd 818-781-2081 F/T 1 (TA, SP)Lourdes Aquino, DDS #01887914435 Sherman Way Ste 107 818-785-7498 F/T 1 (SP, TA) U

Maclay Bromont Family Dtl Grp #02274114435 Hamlin St Ste 104 818-781-0004 P/T 1 (SP, RU) U

Mc Dental #02104514306 Victory Blvd 818-786-6000 P/T 1 (SP, TA) U

Mehrzad Firouzbakht, DDS #02511914100 Victory Blvd 818-908-9199 F/T 1 U

Plaza Dental Clinic #0063987028 1/2 Van Nuys Blvd 818-780-8555 F/T 1 (SP, PE) U

Ricardo And Maria Pellegrini #02524714435 Hamlin St Ste 210 818-908-4090 F/T 2 (SP, IT)

Sherman Way Dental Group #1C80017120 Hayvenhurst Ave Ste 205 818-988-1642 F/T 1 (AM, AR)Sinai Dental Group #01278114550 Haynes St Ste 101 818-780-7555 F/T 1 P/T 4 (PE, SP) U

Sinai Dental Group #02386614523 Sherman Way 818-787-7300 F/T 1 P/T 1 (PE, SP) U

Smilecare-Valley #00400015643 Sherman Way Ste 300 818-786-2209 F/T 2 P/T 7 (SP) U

The Dental Care Center #3946017068 Sepulveda Blvd 818-781-1533 P/T 1 (SP, TA)Universal Care Dental #12770114600 Sherman Way Ste 100 818-756-6950 F/T 7 P/T 5 (SP, TA) U

Valley Dental Center #01259216440 Vanowen St 818-785-5445 P/T 2 (SP, AM, AR, VI, FR)West Coast Dtl Gp of Van Nuys #01387513716 Sherman Way 818-988-2020 P/T 2 (PE, TA, SP) U

VENICECastle Dental Center #0159521440 Lincoln Blvd 310-399-9900 F/T 4 P/T 5VENTURAAmerident Group #2C52016555 Telephone Rd Ste 8 805-642-2790 F/T 2 U

Main Street Dental Group #0164444360 E Main St Ste C 805-644-6110 P/T 2 (SP)Mission Dental Group #2C970126 S Garden St Ste I 805-648-1090 P/T 1 (SP) U

Pacific View Dental Group #0156053585 Telegraph Rd Ste C 805-676-1611 P/T 1 (FR, SP, PE, GR) U

The Delicate Art of Dentistry #0216831437 S Victoria Ave Ste C 805-644-9000 F/T 1 (RU, SP) U

Ventura Dental Group #199601001 Partridge Dr Ste 210 805-644-9501 P/T 2 (SP) U

Woodside Dental Care #00410910883 Telegraph Rd 805-647-1322 F/T 2 P/T 1VICTORVILLEDesert Dental Group #01990012640 Hesperia Rd Ste A 760-241-3336 F/T 6 P/T 1 (AR, TA) U

Desert Sky Dental Group #02105215667 Roy Rodgers Dr #101 760-843-5824 P/T 2 (SP)Desert Valley Dental Group #39090113622 Bear Valley Rd Ste 10 760-245-2010 F/T 1 P/T 1 (SP) U

Dr Hattar Dental #02989715366 Eleventh St Ste F 760-243-3595 P/T 1Procare Dental #03250212602 Amargosa Rd Ste D 760-951-9997 P/T 2 (SP, TA) U

Roy Soriano DDS & Assoc #02263915165 Seventh St Ste I 760-245-7704 F/T 1 (SP, TA)S M Bhatt, DDS #30640114495 Seventh St Ste A 760-245-7800 F/T 3 P/T 6 (HI, RU, SP)Victor Valley Dental Group #02608814689 Valley Ctr Dr Ste E101 760-245-0151 P/T 2 U

Viewpoint Dental Associates #00871315366 Eleventh St Ste G 760-245-8616 F/T 1 P/T 2 (SP, AR, RU) U

VISTACrossing Dental #0140803211 Business Park Dr Ste A 760-598-8881 F/T 1 (SP) U

Gerald Moore, DDS #002708610 S Melrose Dr 760-941-9000 P/T 1 (SP)La Jolla Townsite Fmly Dtl #029747706 Townsite Dr 760-724-4392 P/T 1 U

Melrose Square Dental Group #0138721680 S Melrose Dr Ste 108 760-727-6800 P/T 1

North County Dental Care #0234331000 E Vista Way 760-940-4266 F/T 2 (SP) U

Pearl Dental Family Practice #025817771 E Vista Way Ste 101 760-560-0600 F/T 1 (AR, SP)Smilecare-Vista #0031041010 E Vista Way Ste A B 760-940-8811 F/T 1 P/T 8 (SP)Vista Dental Group #006693435 B South Melrose Drive 760-758-7580 P/T 1Vista Family Dental Center #026702985 S Santa Fe Ave 760-940-8410 F/T 1 P/T 2 (SP) U

Vista Village Fmly Dentistry #032370950 Civic Center Dr Ste B 760-208-4030 F/T 1 (PE, SP)WALNUTTein Chun Wang, DDS #3644011309 N Grand Ave 909-594-7899 F/T 1 (CA, CH, SP)Walnut Hills Family Dentistry #00065218758 Amar Rd 626-912-5599 P/T 2 (FR, SP, AR)WALNUT PARKAlameda Dental Group #0271657700 Alameda St # A 323-585-9200 P/T 1 (Sp) U

WEST COVINAAmerican Dental Group #031087436 N Sunset Ave 626-337-7271 F/T 1 P/T 1Bright Now Dental #0135961400 W West Covina Pkwy 626-338-4848 F/T 3 P/T 10 (SP) U

Dental Care By Blanco #002091 1031 E Amar Rd 626-330-6655 F/T 1 (SP) U

Dental Max #0289352360 S Azusa Ave Ste B 626-839-5010 F/T 1 (SP)Garvey Dental Office #0140451415 W Garvey Ave N Ste 101 626-851-0020 P/T 1 (SP, TA) U

Gateway Dental and Braces #029566662 S Sunset Ave 626-337-9494 F/T 3 P/T 1 (PE, SP) U

Gina Barrameda, DMD #0040741519 E Amar Rd 626-964-6799 P/T 2 (TA) U

Joven Professional Dtl Corp #031443150 S Glendora Ave 626-919-2322 F/T 2 (SP, TA) U

Lin Ma, DDS #017943358 N Azusa Ave 626-966-4514 F/T 1 (SP, CH)Maninder Singh, DDS #3148011312 W Francisquito Ave # D4 626-918-0171 F/T 1 (HI, SP)Newport Dental #003510151 N Azusa Ave 626-331-0076 F/T 3 P/T 15 (SP)Queens Dental Group #329601910 S Sunset Ave Ste 4 626-337-6166 F/T 2 P/T 1 (HI, SP, TA, VI)Rafik Yanni, DDS #2210012413 S Azusa Ave 626-913-1421 F/T 3 (AR, SP, VI) U

Robert Dinh, DDS., Inc #0228841414 S Azusa Ave Ste B-16 626-919-0415 F/T 1 (SP, VI)Smartcare Dental Practice #011835415 S Glendora Ave Ste A 626-918-8338 F/T 1 (SP, TA)Smilecare-West Covina #0035121215 W West Covina Pkwy 626-962-8911 F/T 1 P/T 7 (SP) U

Southern Calif Dtl Ser #3550011014 S Glendora Ave 626-918-2886 F/T 1 (CH, SP)West Covina Family Dentistry #160201450 S Glendora Ave Ste 106 626-856-3317 F/T 2 P/T 7 (HI, SP, RU, TH) U

West Covina Smiles #0184913660 S Nogales St Bldg H #D 626-810-9600 F/T 1 (SP) U

WEST HILLSFallbrook Dental Group #0213926739 3/4 Fallbrook Ave 818-592-6060 F/T 1 (PE, SP) U

Gentle Dentistry #0234727138 Shoup Ave Ste B7b8 818-883-7070 F/T 1 U

Medical Center Dental Care #0107917325 Med Ctr Dr Ste 101 818-348-6068 P/T 1 (SP) U

Platt Village Dental Group #0157346446 Platt Ave 818-716-7001 P/T 2 (SP) U

Stephen Cheung, DDS #01326623101 Sherman Pl Ste 417 818-348-9595 F/T 1 (CA, PE, HE, SP) U

WEST HOLLYWOODA West Hollywood Sunset Dtl #0175289201 W Sunset Blvd Ste 808 310-858-8656 P/T 1 (HE, PE, SP) U

Eva Dloomy, DDS #3930019201 W Sunset Blvd Ste 501 310-278-9121 F/T 1 (AR, FR, HE, SP) U

Omid Farahmand, DMD #0118419201 W Sunset Blvd Ste 915 310-273-3650 F/T 1 (PE) U

WESTCHESTERBenjamin Rosenberg, DDS #0027828540 S Sepulv Blvd Ste 1000 310-649-2430 F/T 1 (SP, HE) U

Westchester Dental Care #1610018930 S Sepulv Blvd Ste 117 310-641-8890 F/T 1 (SP, TA, PE) U

WESTLAKE VILLAGEFinesse Dental Care #016471860 Hampshire Rd Ste E 805-777-7447 P/T 1 (HE, SP) U

Ghotanian DDS PC #001508870 Hampshire Rd Ste C 805-497-2260 F/T 2 (SP) U

Sona Georgian, DDS #01174032144 Agoura Rd Ste 213 818-991-4664 F/T 1 (AM, RU, Sp)WESTMINSTERNewport Dental #00449115458 Beach Blvd 714-898-3220 F/T 6 P/T 11 (SP, VI) U

Thanh Ngoc Nguyen DMD Inc #11540115355 Brookhurst St Ste 101 714-531-5175 F/T 2 (VI) U

WHITTIERAtlantic Dental Group #0049096716 Greenleaf Ave 562-696-5544 F/T 2 (PE, SP) U

Beverly Family Dental #01747711822 Floral Dr Ste D 562-692-7870 F/T 1 (PE)Darrel Dagdigian, DDS #25180116406 Whittier Blvd 562-694-0396 F/T 2 (KO, SP, VI) U

Friendly Hills Fmly Dentistry #39670114544 Whittier Blvd 562-698-9855 F/T 1 (HI, SP) U

Merle Yaneza, DDS #01972510420 Whittier Blvd 562-463-3332 P/T 1 (SP, TA)Mitra Rouintan, DDS #0251929209 Colima Rd Ste 2200 562-693-4108 F/T 1 (PE, SP)Rodolpho Burquez, DDS #00002611574 Hadley St 562-699-3838 F/T 1 U

So Cal Family Dentistry #00250114412 Whittier Blvd 562-693-0788 F/T 1 (SP, PE)St Mary Medical Building #0229987743 Painter Ave Ste B 562-698-7113 P/T 1 (SP)The Village Dental Center #0160106742 Greenleaf Ave Ste 300 562-945-1684 F/T 1 (SP, HI)Thomas Trinh, DDSInc #0203079150 Painter Ave # 105 562-320-3333 F/T 1 (SP) U

Uptown Dental Group #0131586711 Greenleaf Ave 562-698-0054 F/T 1 (CH, SP) U

Whittier Dental Center #28350114564 Whittier Blvd 562-693-8202 F/T 1 P/T 1 (PE, KO, SP)WILDOMARBear Creek Dental Group #01129136068 Hidden Springs Rd # H 951-678-0790 F/T 1 P/T 1 (SP) U

Clinton Keith Dental Group #01072323905 Clinton Kth Rd Ste 108 951-304-9700 P/T 1 (SP)Upland Dental Implnt & Ortho #02170234859 Fredrick St Ste 106 951-678-9888 P/T 1 (SP, CH) U

Wildomar Dental Care #02627232100 Clinton Keith Rd Ste E 951-678-4300 F/T 1 (SP, VI)WILMINGTONDental Office #017527445 E Anaheim St Ste M 310-835-3535 P/T 1 U

Jin Yang, DDS #016541200 E Anaheim St Ste 254 310-830-3344 F/T 1 (SP) U

Lucy Cabieles, DDS #0186061455 N Avalon Blvd 310-835-1842 F/T 1 (SP) U

Vaishali Patel, DDSInc #021646207 W G St 310-549-2400 F/T 1 (SP, HI, EI)Wilmington Dental #0127401610 N Avalon Blvd 310-835-3131 F/T 4 P/T 8 (PE, SP)Wilmington Family Dentistry #002867851 W Pacific Coast Hwy 310-830-3620 F/T 1 (KO, SP) U

WINCHESTERWinchester Dental Center #1C510133040 Simpson Rd 951-926-2489 F/T 1 (KO, SP)WINNETKAEdwin Papazian DDS., Inc #0028537616 Winnetka Ave Ste 1 818-772-6222 F/T 1 (AM, SP, PE) U

Sky Dental Group #02386419725 Vanowen St 818-347-6060 F/T 1 (PE, SP)WOODLAND HILLSAffinity Dental Group #0305535312 Comercio Ln Ste B 818-884-4338 P/T 1Around The Corner Dental Spa #01139822030 Clarendon St Ste 102 818-999-4445 F/T 1 (PE, SP, TA)Cosmetic Laser Dentistry #01573522062 Ventura Blvd 818-676-1485 P/T 1 (SP, GE, AR)Ebrahim Mikail, DDS #01227922636 Ventura Blvd 818-591-0123 F/T 1 (PE) U

Edward Rosen & Associates #01368921500 Ventura Blvd Ste 200 818-999-6165 F/T 2 P/T 3 (AM, CH, PE, RU, SP) U

Hamid Imankhan, DDS #02312723111 Ventura Blvd Ste 104 818-225-7768 F/T 1 (SP, PE, FR)Nader Ahdout, DDS #00282922116 Ventura Blvd 818-340-3062 F/T 1 (SP, PE)Pivnick And Rosen DDS #0C80016325 Top Cyn Blvd Ste 518 818-346-8840 F/T 1 P/T 1 (SP) U

Taft Plaza Dental Group #02782520046 Ventura Blvd 818-716-0297 F/T 3 (AM, SP, FR, RU, PE) U

Topanga Dental Care #02040421839 Ventura Blvd 818-347-8444 F/T 1 (AR, AM, SP) U

YORBA LINDAEastlake Village Dental #01556320429 Yorba Linda Blvd 714-695-9530 P/T 2 (SP, PE) U

Nilar Thein, DDS #00636117540 Yorba Linda Blvd 714-996-4057 P/T 2 (SP) U

Richard Hamaty, DMD #01752218509 Yorba Linda Blvd 714-779-1313 P/T 1Yorba Linda Dental Arts #02202019831 Yorba Linda Blvd Ste A 714-693-0990 P/T 2 (PE) U

Yorba Linda Dental Center #16040121560 Yorba Linda Blvd Ste C 714-779-7675 F/T 2 (CH, SP) U

Yorba Linda Dental Group #01153918432 Yorba Linda Blvd Ste D 714-970-2801 P/T 2 U


PREDICTABLE COSTS With KPIC’s group dental insurance plan you know exactly

how much KPIC will pay for a covered dental service. Just refer to the Table of Allowances on pages 4 and 5 of this brochure to see how much KPIC will pay for each covered dental service.

NO DEDUCTIBLE ON DIAGNOSTIC AND PREVENTIVE SERVICES Your calendar year deductible is $50 per person, up to a

maximum of $150 for the family. There is no deductible on diagnostic and preventive services. Your benefits cover a maximum of $1,000 of dental services for each covered enrollee per calendar year.

When you enroll in KPIC’s group dental insurance plan, you are enrolling for a period of one year. This does not apply if your employment is terminated.

WAITING PERIODS Some of the covered dental services listed in the Table

of Allowances are subject to a waiting period. This is the period of time that you and your covered dependents are required to have been continuously covered under KPIC’s group dental insurance plan before a specific dental service will be a covered benefit. Consult the Table of Allowances on pages 4 and 5 of this brochure for the specific dental services that are subject to a waiting period.

n BENEFITS KPIC’s group dental insurance plan covers the following

benefits when they are provided by a licensed dentist and when necessary and customary by the standards of generally accepted dental practice:

I. DIAGNOSTIC AND PREVENTIVE BENEFITS Diagnostic: oral examinations x-rays diagnostic casts biopsy/tissue examinations emergency palliative treatment specialist consultations

Preventive: prophylaxis treatments (cleanings) fluoride treatments space maintainers

Limitations on Diagnostic and Preventive Benefits • Benefits for oral examinations are limited to two

exams in any calendar year while the patient is covered under any KPIC dental insurance plan.

• Prophylaxis treatments are limited under General Limitations.

• Full mouth x-rays are covered only after five years have elapsed following any prior provision of full mouth x-rays under any KPIC dental insurance plan. Bitewing x-rays are covered on request by the dentist,

but not more than twice in a calendar year for children through 18, and once in a calendar year for adults, while the patient is an eligible person under any KPIC dental insurance plan.

II. BASIC BENEFITS Oral surgery: extractions and certain other surgical

procedures, including pre- and postoperative care

Restorative: amalgam, silicate or composite (resin) restorations (fillings) for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay)

Endodontic: treatment of the tooth pulp (root canal treatment)

Periodontic: treatment of gums and bones supporting the teeth

Sealants: protective coating for posterior molar teeth

Limitations on Basic Benefits Periodontal procedures which include prophylaxis are

limited under General Limitations.

Sealants are available for first molars for eligible persons through age 8 and for second molars for eligible persons through age 15. The benefit includes the application of sealants only to permanent first and second molars with no caries (decay), with no restorations and with the occlusal surface intact. The sealants benefit does not include the repair or replacement of a sealant on any tooth within three years of its application.

III. CROWNS, INLAYS, ONLAYS AND CAST RESTORATION BENEFITS

Crowns, inlays, onlays and cast restorations will be covered when teeth cannot be restored with amalgam, synthetic porcelain or plastic restorations.

Limitations on Crowns, Inlays, Onlays and Cast Restoration Benefits

Crowns, inlays, onlays and cast restorations will be replaced only after five years have elapsed following any prior provision under any KPIC dental insurance plan.

IV. PROSTHODONTIC BENEFITS Procedures for construction or repair of fixed bridges,

partial or complete dentures.

Limitations on Prosthodontic Benefits Prosthodontic treatment is subject to a six-month

period. See Table of Allowances for further reference.

2 35

SEAL BEACHGilbert Unatin, DDS #1447011900-A Saint Andrews Dr 562-430-1054 F/T 2 P/T 1Maged Zaky Nessim DDS., Inc #0000561058 Bolsa Ave 562-594-4885 P/T 1 (SP, AR)SHERMAN OAKSAnait Alabyan, DDS #0189114910 Van Nuys Blvd Ste 200 818-788-2121 F/T 1 (AM, RU, SP)Comfort Care Dental #0267585151 Hazeltine Ave 818-788-2023 F/T 2 (AM, SP, TA, AR)David Isaacs, DDS., Inc #0323294350 Woodman Ave 818-981-4508 F/T 1 (AF, HE, SP)Karen Arakelian, DDS #3C51014940 Van Nuys Blvd Ste 102 818-995-3377 F/T 1 (AM, RU, SP)KW Cheng & V Thay Inc #00760413732 Ventura Blvd 818-907-9533 F/T 1 P/T 1 (AM, CA, SP, VI) U

Sherman Oaks Cosmetic Dlt Grp #0295154955 Van Nuys Blvd Ste 520 818-990-4121 P/T 3 (AM, TA) U

SIMI VALLEYAnit Natt, DDS #0023791420 E Los Angeles Ave Ste D 805-581-1191 F/T 1 (SP) U

Boris Zak, DDS #3331014537 Alamo St Ste A 805-520-1100 P/T 1 U

Dental Care of Simi Valley #1761011687 Erringer Rd Ste 201 805-527-3534 F/T 1 (AM, PE, SP) U

Dental Center Of Simi Valley #0114004210 E Los Angeles Ave Ste F 805-579-0600 P/T 1 (AM, GE, PE, SP) U

First Street Dental Group #0126851197 E Los Angeles Ave Ste E 805-583-5700 F/T 1 (PE, SP, TA) U

Kostantinos Proussaefs, DDS #0225571445 E L.A. Ave Ste 300 805-526-8296 F/T 1 (GR, SP) U

Ralph Maiello DDS, Inc #253401495 E Los Angeles Ave 805-584-2228 F/T 2 P/T 2 (SP, VI)Simi Valley Dental Group #0063622410 Sycamore Dr Ste A 805-522-2600 F/T 1 P/T 1 (SP)Simi Valley Smiles #0291852650 Tapo Canyon Rd Ste 107 805-522-5516 P/T 2 (SP) U

Smile Planet Dental Group #0333372486 Erringer Rd 805-520-0100 P/T 2 (PE, SP) U

Ted Chaffee, DDS #0208582950 Sycamore Dr Ste 103 805-527-6400 F/T 1 (SP) U

SOLANA BEACHAblantis Dental #012881130 S Solana Hills Dr 858-259-8400 F/T 1 (SP) U

SOUTH EL MONTEAtlas Dental Care #0323373131 Santa Anita Ave Ste 201 626-444-2605 F/T 2 (PE, SP, VI)Dr Beri’s Dental Office #02274010496 Garvey Ave 626-442-5678 P/T 1 (HI, SP) U

Durfee Dental Office #0031352001 Santa Anita Ave Ste 204 626-443-3915 F/T 4 (CH, JA, SP, TA, VI)Garvey Dental Center #0213959328 Garvey Ave Ste A 626-350-0588 P/T 1 (CH, SP, VI) U

Tyler Dental Care #0189031928 Tyler Ave Ste D168 626-443-7922 F/T 1 (KO, SP)Universal Family Dental #01274710012 Garvey Ave Ste 11 626-433-1300 P/T 1 (SP, VI) U

Whelan Lok, DDS., Inc #01366010050 Garvey Ave Ste 105 626-444-4220 F/T 2 (CH, SP, CA) U

SOUTH GATEAdult & Childrens Dental Grp #1146014444 Tweedy Blvd 323-564-2444 F/T 25 P/T 1 (CH, PE, SP, TA) U

Castle Dental Center #0160114433 Tweedy Blvd 323-567-1227 F/T 5 P/T 4Dr Naziri Dental Clinic Inc #0127124186 Tweedy Blvd 323-569-7131 F/T 2 (PE, SP)Family Dental Center #0246505814 Imperial Hwy 562-869-2755 F/T 1 (HI, SP)Henry Shafajoo, DDS #0167622639 Santa Ana St 323-583-1481 P/T 1 U

Leticia J Jacobs, DDS #0232408200 Long Beach Blvd Ste E 323-581-0707 F/T 1 (SP) U

Magdy Tadros Family Dentistry #0246593173 Tweedy Blvd 323-564-4554 F/T 1 (AR, SP)Omid South Gate Dental #01351510530 Atlantic Ave 323-569-5000 P/T 1 (PE, SP) U

Perfect Smile #0131645863 Imperial Hwy Ste 2A 562-862-1345 F/T 1 P/T 1 (PE, SP) U

Samir Khayal, DDS #0251205841 Firestone Blvd Ste C 562-806-8611 F/T 1 (SP)West Coast Dental #2852014149 Tweedy Blvd Ste G 323-567-3333 F/T 1 P/T 2 (SP) U

SOUTH PASADENACaliforniasmile.Net #0052201506 Huntington Dr 626-799-2888 F/T 1 (SP) U

Healthy Smile Fmly Dentistry #0110271315 Fair Oaks Ave Ste 103 626-799-8068 P/T 2 (CH, SP) U

SPRING VALLEYCharlie Carmichael, DDS #3966018300 Prds Vly Rd Ste 122 619-479-9143 F/T 1 (TA)Smileburst Dentistry #1 #020927645 Sweetwater Rd 619-464-0426 P/T 3 (SP, TA, KO) U

STANTONJeffrey Chu, DDS., Inc #0032037025 Katella Ave 714-229-1234 P/T 1 (CA, CH, SP, TA, TH) U

Smile Academy #01748212793 Beach Blvd 714-903-9963 F/T 1 P/T 1 (HI, SP) U

Smile Family Dental #0165467757 Katella Ave Ste D 714-209-7702 F/T 1 (SP, CH) U

Stanton Dental #01259711001 Beach Blvd 714-891-6623 F/T 2 P/T 11 (SP) U

STUDIO CITYRoyal Dental Spa #01613811711 Moorpark St 818-505-1211 P/T 1 (AM, RU, SP) U

S C Dental Care #0054844366 Tujunga Ave 818-985-5462 P/T 2 (SP, PE)SUN CITYMc Call Dental Practice #02931228115 Bradley Rd Ste 3 951-723-1188 P/T 1Menifee Dental Group #00753729950 Haun Rd Ste 302 951-679-1667 P/T 1 (SP) U

Sun City Dentistry #02991427851 Bradley Rd Ste 155 951-679-0520 F/T 1 (PE)SUN VALLEYDrs Mishra & Kripalani #0110308381 Laurel Canyon Blvd 818-768-7800 F/T 1 P/T 1 (HI, SP)Family Dentistry #3799018805 Sunland Blvd 818-767-5243 F/T 1 P/T 1 (SP, TA) U

Fresh Smile Dental Center #0227718215 Sunland Blvd 818-252-7222 F/T 1 (PE, SP) U

Universal Care Dental #1280019375 San Fernando Rd Ste 602 818-504-9876 F/T 3 P/T 5 (CH, FR, IT, SP)SUNLANDSunland Dental Care #1341017902 Foothill Blvd 818-353-5520 P/T 2 (SP, AM, PE) U

Sunland Family Dentistry #0106448522 Foothill Blvd 818-352-8888 P/T 1 (RU, SP, AM) U

SYLMARKings Family Dental Group #02591214124 Foothill Blvd Ste 103 818-364-9444 F/T 1 P/T 1 (SP) U

Saint Mina Family Dental #02248812601 San Fernando Rd Ste H 818-364-1991 F/T 1 (AR, SP, FR) U

Sinai Dental Group #01328513060 Glenoaks Blvd Ste 105 818-899-1800 F/T 1 P/T 2 (PE, SP, TR, AM) U

TARZANAAngela Hoffman, DDS/. Inc #0171225620 Wilbur Ave Ste 316 818-345-7720 P/T 1 (RU, SP) U

Dental Plus Tarzana #03163019534 Ventura Blvd 818-881-2333 F/T 1 (FR, SP)Fara Salehi, DDS #35640118740 Ventura Blvd Ste 105 818-344-3357 F/T 1 (Pe, Ru, Sp)Shahin Shamsian, DDS #0047965620 Wilbur Ave Ste 309 818-881-1559 P/T 1 (SP, PE, TA) U

Theodore Stomel, DMD #01432919525 Ventura Blvd 818-708-7101 P/T 2 (RU, SP)TEHACHAPIValley Family Dentistry #2C890120300 W Valley Blvd Ste A 661-822-1134 F/T 1 P/T 1 U

TEMECULABright Now! Dental #01435630571 Temecula Pkwy Ste D 951-693-2079 F/T 1 P/T 9 (SP) U

Bright Now! Dental #02325939804 Winchester Rd Ste B 951-695-7100 P/T 11 (SP) U

Butterfield Dental #02459233321 Temecula Pkwy Ste 104 951-302-7508 P/T 1 (SP, CH, VI) U

Creekside Dental #02568541785 Nicole Ln # A3 951-699-3250 F/T 1 U

Dental Associates of Temecula #00422340820 Winchester Rd Ste 1500 951-296-6788 F/T 1 P/T 1 (SP) U

Friendly Dental Center #02614028314 Old Town Front St 951-676-8920 P/T 1 (SP, VI) U

Lynda Watanabe Dtl Corp #3C710127487 Ynez Rd 951-699-2144 P/T 1Margarita Esthetics Family #03379429049 Overland Dr Ste C 951-506-4900 F/T 1 U

Meadows Dental Group #01760631843 Rch Ca Rd Ste 300 951-676-2613 F/T 1 P/T 1 (SP) U

Pacific Dental Group #00642231754 Temecula Pkwy 951-694-5255 F/T 2 P/T 1Peter Bishay, DDSInc #02425028999 Old Twn Frnt St # 208 951-695-0310 P/T 1 (SP, FR, AR) U

Rubin Nichols, DDS #02422726475 Ynez Rd 951-296-9661 P/T 2 U

Smilecare-Temecula #00388740620 Winchester Rd Ste B 951-719-3182 F/T 2 P/T 1 (SP) U

Temecula Dental Group #25310141593 Winchester Rd Ste 211 951-296-3366 F/T 2 P/T 4 (SP, TA) U

TEMPLE CITYFriendly Dental Care #02235510455 Lower Azusa Rd 626-444-3744 F/T 1 (AM, CH, FR, PE, RU, SP)Happy Smile Dental #0299679600 Las Tunas Dr 626-286-9600 F/T 1 (CH, VI) U

THOUSAND OAKSAlex Bierman, DDS #029564223 E T. O. Blvd Ste 209 805-495-1061 F/T 1Dar Radfar, DDS #0155621459 E T. O. Blvd Ste B 805-497-9408 F/T 1 (SP, PE, FR)

East Oaks Dental Group #013796593 N Moorpark Rd Ste B 805-494-5255 F/T 1 P/T 1 (SP) U

Lombard Dental Group #244501245 Lombard St 805-495-2431 F/T 3 (AM, PE, SP, TA) U

Mojgan Hashemi, DDS #363301415 Rolling Oaks Dr Ste 120 805-449-9952 F/T 1 (PE, SP, VI)New Age Family Dental #0202841429 E T. O. Blvd Ste 101 805-230-9212 P/T 1 (PE, SP)Peter Sabolch, DDS #147501394 Lombard St 805-379-5222 F/T 1 (SP) U

Prism Dental Group #030675355 E Ave Arboles Ste A 805-241-5353 P/T 1 (HI) U

Royal Dental Spa #0130641459 Thousand Oaks Blvd # A 805-494-1831 F/T 1 (FR, PE, RU, SP)Skyline Dental #0242562875 E Thousand Oaks Blvd 805-496-2200 F/T 1 (PE, SP) U

Thousand Oaks Dental Group #0063631760 E Ave Arboles Ste A 805-493-5200 P/T 1 U

Westlake Smile Center #0320183665 E Thousand Oaks Blvd 805-496-3347 F/T 1 P/T 1 (HU, PE, SP) U

TIJUANADenticenter #322301Ave Circuito Bursatil9301202 619-482-0200 F/T 1 (SP)TOLUCA LAKEEsteban Bonilla, DDS #0C440110745 Riverside Dr Ste B 818-980-2887 F/T 1 (CH, SP) U

Tina Ghotanian, DDS #3C300110916 Riverside Dr 818-762-9966 F/T 2 (AM, SP)TORRANCEAll Care Dental #02995919019 Hawthorne Blvd 100 B 310-371-0113 P/T 1All Smiles Family Dntl Group #00137018506 Hawthorne Blvd 310-338-0444 F/T 1 P/T 2 (CH, PE, SP) U

Beautiful Smile Dental Center #0142521431 W Knox St Ste 800 310-320-1180 P/T 1 (SP, RU) U

Beaverly Grace Catalan, DMD #02167922759 Hawthorne Blvd 310-373-9522 F/T 1 (SP, TA) U

Blue Sky Dental Group #01266017311 Yukon Ave 310-324-3333 P/T 1 (PE, SP) U

Dental Assoc of Torrance #01880521229 Hawthorne Blvd Ste A 310-792-5600 F/T 1 P/T 1 (SP) U

Downtown Family Dental #0096062055 Torrance Blvd 310-320-0707 F/T 1 P/T 3 (SP, TA, HI, GE, RU) U

Dr Campbell Century Dental #0135381270 Sartori Ave 310-320-1471 P/T 2 (KO, SP)E Dental #03083724422 Hawthorne Blvd Ste A 310-378-2400 P/T 1 (KO, SP, TA) U

Joshua C H Chiu DDS., Inc #00181021320 Hawthorne Blvd Ste 212 310-543-1003 F/T 1 (CH, JA) U

Redondo Beach Dental Clinic #0214962130 Redondo Beach Blvd 310-768-8281 F/T 1 (SP, CA, CH) U

Smilecare-Torrance #003954923 W Carson St 310-533-1300 F/T 1 P/T 7 (SP) U

Torrance Dental Arts #0C870123326 Hawthorne Blvd Ste 190 310-378-8209 P/T 2 (SP, TA) U

Torrance Dental Associates #34730117305 Crenshaw Blvd 310-327-4166 F/T 2 (PE, SP, TA) U

Torrance Dental Center #01120021150 Hawthorne Blvd Ste 101 310-371-0777 F/T 1 P/T 1 (SP, PE, TA) U

Universal Care Dental #1279011001 W Carson St Ste E 310-618-1522 F/T 3 P/T 5 (CH, FR, IT, SP) U

Village Family Dental #2C42011235 Sepulveda Blvd 310-530-9656 F/T 1 P/T 1 (GR, VI, SP) U

West Coast Dental #3560011730 Sepulveda Blvd Ste 1 310-325-8888 P/T 1 (CH, SP) U

William G Zakaria, DDS #0124434350 Redondo Beach Blvd 310-370-2966 F/T 1 (AR)TUSTINA A Family Dental Group #00282718102 Irvine Blvd Ste 205 714-731-5656 F/T 2 P/T 1 (SP, HI, PE, VI, TA) U

Amit Shah, DDS #01153017602 17th St Ste 105 714-544-7511 P/T 1 (SP) U

Bella Dental Group #01994714122 Red Hill Ave 714-544-8338 F/T 1 (SP, AR, PE) U

Calvin Mclemore III, DDS #03265517482 Irvine Blvd Ste B 714-508-0995 P/T 1Elmer Yoshida, DDS #017217137 W 1St St Ste B2 714-730-9900 F/T 1 (JA, SP)Heba Guirguis, DDS #02991614151 Newport Ave Ste 100 714-505-1641 F/T 1 (SP) U

Kay Kim Dental #01583813132 Newport Ave Ste 220 714-505-2010 F/T 1 (KO) U

Nadia Rezaiamiri, DDS #00018813372 Newport Ave Ste F 714-665-0898 F/T 1 P/T 1Simona Kiss, DDS #01493918102 Irvine Blvd Ste 201 714-730-9656 F/T 1 (SP, RO, HU) U

Smile Dental Care #03315014001 Newport Ave Ste C 714-508-8500 F/T 1 (SP, VI) U

Southland Dental Arts #00438513771 Newport Ave Ste 11 714-838-3230 F/T 1 P/T 1 (SP, VI) U

Tustin Dental Care #01165112575 Newport Ave Ste B 714-731-6100 P/T 1 (AR, SP) U

Tustin Dental Office #1C620113721 Newport Ave Ste 1 714-368-1400 P/T 3 (SP) U

Tustin Smile Care #03331212791 Newport Ave 3200 714-665-0005 F/T 2 (HI, SP) U

UPLANDAlta Dental Care #021409 1113 Alta Ave Ste 205 909-985-6116 F/T 1 (SP) U

Crossroads Dental Group #0137971875 N Campus Ave Ste C 909-985-2302 P/T 2 (SP) U

Daniel Duroseau, DDS., Inc #033181930 W Foothill Blvd Ste D 909-608-2390 F/T 1 (FR, SP)Danny Lee, DMD #0327141049 W Foothill Blvd 909-985-1966F/T 1 P/T 1 (KO, SP) U

Douglas Johnson, DDS #017301980 E Foothill Blvd Ste 104 909-981-3341 F/T 1 (SP) U

Eric Chiang, DDS #0002321273 W 7th St 909-920-9543 F/T 1 (CH, SP) U

Magnolia Town Dental #029966258 E 9th St 909-946-3433 F/T 1 (GE, SP, FR) U

Steven Chiu, DDS., Inc #0334351183 E Foothill Blvd Ste 150 626-965-5618 P/T 1 (CH) U

Upland Dental Aesthetics #030554121 W Foothill Blvd Ste E 909-982-9800 F/T 1 (SP) U

Upland Smiles #029561270 E 7th St Ste 2C 909-982-8501 F/T 1 (SP) U

Yuen Siang Hung, DDS #3673011268 W Foothill Blvd 909-981-4111 P/T 1 (SP) U

VALENCIABaywood Dental Group #01235224121 Baywood Ln Ste A 661-291-1200 F/T 2 P/T 1 (Sp) U


• Prosthodontic appliances, including but not limited to fixed bridges and partial or complete dentures, will be replaced only after five years have elapsed following any prior provision of such appliances under any of KPIC’s dental insurance plans, except when KPIC determines that there is such extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory. Replacement will be made of a prosthodontic appliance not provided under a KPIC dental insurance plan if it is unsatisfactory and cannot be made satisfactory.

• KPIC group dental insurance plan will pay the listed allowance toward the dentist’s fee for a standard cast chrome or acrylic partial denture or a standard complete denture. (A “standard” complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials.)

• Implants (materials implanted into or on bone or soft tissue), or the removal of implants, are not benefits under this insurance plan. However, if implants are provided in connection with a covered prosthetic appliance, KPIC will make an allowance up to the listed allowance for a standard complete or partial denture toward the cost of implants and the prosthetic appliances. If KPIC makes an allowance toward the cost of such procedures, KPIC will not pay for any replacement placed within five years thereafter.

V. GENERAL LIMITATIONS — PROPHYLAXIS TREATMENTS AND OPTIONAL SERVICES

• Benefits under this insurance plan shall include only the first two prophylaxis treatments (cleanings) or single procedures which include prophylaxis, or combination thereof, provided to a patient in any calendar year while he or she is an eligible person under any KPIC dental insurance plan.

• If an eligible person selects a more expensive plan of treatment than is customarily provided, or specialized techniques rather than standard procedures, KPIC will pay the listed allowance for the lesser procedure, and the patient is responsible for the remainder of the dentist’s fee (examples: a crown where a silver filling would restore the tooth or a precision denture where a standard denture would suffice).

VI. SERVICES NOT COVERED (EXCLUSIONS) • Services for injuries or conditions which are

compensable under Workers’ Compensation or Employers’ Liability Laws; services which are provided to the eligible person by any federal or state government agency or are provided without cost to the eligible person by any municipality, county or other political subdivision, except as required by law.

• Services for restoring tooth structure lost from wear, for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion or for stabilizing the teeth. Such services include but are not limited to equilibration and periodontal splinting.

• Prosthodontic services or any single procedure started prior to the date the person became eligible for such services under the Policy.

• Prescribed or applied therapeutic drugs, premedication or analgesia.

• Experimental procedures.

• All hospital costs and any additional fees charged by the dentist for hospital treatment.

• Charges for anesthesia, other than general anesthesia administered by a licensed dentist in connection with covered oral surgery services.

• Extraoral grafts (grafting of tissues from outside the mouth to oral tissues) or implants (materials implanted into or on bone or soft tissue) or the removal of implants, except as provided under Limitations on Prosthodontic Benefits.

• Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joint or associated musculature, nerves and other tissues, unless covered by a rider to the Policy.

• Orthodontic services.

• Procedures not shown on the Table of Allowances.

• Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), unless covered by a rider to the Policy.

To determine exactly how much your out-of-pocket costs will be and what services will be covered, ask your dentist for a predetermination of benefits.

334

Aesthetic Dental Practice #0103854242 Camino Del Rio N Ste 24 619-640-3400 P/T 1 (PE, SP) U

Apple Dental #3C04011540 Fern St 619-236-9549 P/T 1 (CH, SP)Bernardo Dental Office #38560116466 Bernardo Ctr Dr # 185 858-676-1845 F/T 1 U

Bernardo Heights Dental Group #02024915731 Bernardo Hghts Pkw 101 858-674-6813 P/T 2Boulevard Dental Center #0316333531 El Cajon Blvd # A 619-584-8975 F/T 1Bright Care Dental Group #0259143078 University Ave 619-295-8891 F/T 1 (SP, VI, TA)Carmel Plaza Dental Center #01271111738 Carmel Mountain Rd 858-675-1180 F/T 1 (PE, SP, TA) U

Coast Dental Care #0106876585 El Cajon Blvd 619-265-0072 P/T 2 (SP, PE)Cosmetic And Family Dentistry #0141309636 Tierra Gnd St Ste 105 858-549-4511 F/T 1 (AM)Dream Smile #0138334501 Mission Bay Dr Ste 2E 858-270-6626 F/T 1 (PE, TR, SP)Extreme Smile Makeover #0120365927 Balboa Ave 858-751-5733 F/T 1 (SP, PE)Friars Mission Dental Group #0138705638 Mssn Ctr Rd Ste 104 619-293-7164 P/T 1 (SP)Gene Moore, DDS #231301286 Euclid Ave Ste 201 619-263-6683 F/T 1 (SP, CH)Gentle Dental North County #0102749855 Erma Rd Ste 108 858-578-9020 P/T 2Gentle Dental Sorrento Valley #00476711230 Sorrento Vly Rd # 130 858-458-9126 F/T 2 P/T 2Gentle Dentistry #0173064765 Carmel Mtn Rd #205 858-350-7400 P/T 1 (PE, GE, SP)Glenn E. Haldy DDS #1713013670 Clairemont Dr Ste 14 858-273-0540 F/T 1Hillcrest Family Dental Cr #0057353330 3Rd Ave Ste 400 619-291-8750 F/T 1 P/T 3 (TA, SP)Irresistible Smiles #0242394765 Carmel Mountain Rd 203 858-755-8993 F/T 1 (PE, SP) U

James F Misla, DDS #0340423737 Moraga Ave Ste A208 3 858-866-0656 F/T 1 (SP, TA) U

Jerome Bannister, DDS #2C65014370 Palm Ave Ste C 619-428-8682 F/T 1 P/T 1 (SP, TA)Mark Riedler, DDS #3779014167 Ohio St 619-281-6635 F/T 2 (SP, AR)Mesa Dental Group #0138197625 Mesa College Dr Ste 100 858-514-4290 F/T 1 (TA, PE, SP)Mission Bay Dental #3C69014295 Gesner St Ste 2B 619-275-2750 F/T 1 (Sp)Mission Dental Center #0325015995 Mission Gorge Rd Ste A 619-280-6500 P/T 1 (PE, SP)Naser Ostad, DDS #00282612330 Carmel Mtn Rd Ste C4 858-485-0555 F/T 1 (PE)Pacific Dental #0018959330 Mira Mesa Blvd Ste B 858-693-9070 F/T 1 P/T 1 (TA, VI) U

Pearl Cosmetic-Family Dntstry #01895513522 Sabre Spgs Pkwy # 201 858-513-1747 P/T 1 (PE) U

Rancho Dental Group #1895011442 University Ave 619-297-6104 F/T 1 (SP)Ray Derakshan, DMD #02170411134 Rch Carmel Dr Ste 103 858-485-1010 F/T 1 (PE) U

Richard Katnik, DDS #0081017319 Clairemont Mesa Blvd 858-569-9651 F/T 3 (SP, TA)San Diego Dental Arts #0303262168 Balboa Ave Ste 1 858-273-2800 F/T 1Serenity Dental Spa #02817212396 World Trade Dr Ste 208 858-673-1000 F/T 1 (SP, AR) U

Smile San Diego #0316312650 Cam Del Rio N Ste 102 619-298-0521 F/T 1 P/T 2 (SP, TA)Smilecare-Kearny Mesa #0025393820 Convoy St 858-569-1100 F/T 1 P/T 3 (SP)Smilecare-Mira Mesa #0024138997 Mira Mesa Blvd 858-536-5550 F/T 5 P/T 9 (SP)Smilecare-Mission Valley #0024111333 Camino Del Rio S Ste 20 619-260-4990 F/T 5 P/T 8 (SP)Smiles on The Bay #0112903737 Moraga Ave Ste B307 858-273-1631 P/T 1 (SP)Stephen Baral, DDS #252901306 Walnut Ave Ste 36 619-298-2942 F/T 1Sun Smiles Dentistry #01905011120 E Ocean Air Dr # B105 858-792-7823 P/T 1 (SP) U

Sunshine Dental Office #0C20019888 Carmel Mtn Rd Ste B 858-780-8870 F/T 1 (SP)Sunshine Dentistry #0031214230 30th St 619-282-1007 F/T 1 (SP, PE)Tierra Town Dental Center #03113510645 Tierrasanta Blvd Ste B 858-277-6080 F/T 1 (GE, IT, SP, VI) U

Tierrasanta Dental Group #01274210405 Tierrasanta Blvd 858-492-9300 F/T 1 P/T 1 (AR, SP, HI) U

Westview Dental Office #00713313350 Camino Del Sur Ste 6 858-484-9977 P/T 1 (SP)William Carlo, DMD #0221223333 5ThAve Ste 150 619-299-2550 F/T 1 (SP)SAN DIMASBouz Dental Corporation #3C6601639 E Foothill Blvd Ste A 909-599-2029 F/T 1 (AR, RU, SP)Family Dentistry #0116351437 W Arrow Hwy 909-305-6900 F/T 1 (AR) U

Plaza Dental Office #1999011120 Via Verde 909-599-2444 F/T 2 (FR, GE, SP) U

San Dimas Dental Office #011722923 W Arrow Hwy 909-592-5599 P/T 1 (SP) U

Sierra Dental Care #0299521301 W Arrow Hwy Ste 120 909-592-8338 F/T 1SAN FERNANDOAnatoly Vaisman, DDS #00938411273 Laurel Canyon Blvd 818-365-7191 F/T 1California Dental #0192182040 Glenoaks Blvd Ste F 818-361-3889 F/T 2 (AM, RU, SP)Heavenly Dental #020926321 N Maclay Ave Ste A 818-837-9744 P/T 2 (SP, PE, TA)Juan Falabella, DDS #0182921701 Truman St Ste B C 818-837-1660 F/T 1 (SP, TA) U

San Fernando Dental Care #3253011240 Truman St Ste 200 818-365-7107 P/T 1 (SP)San Fernando Dental Center #066801125 S Brand Blvd 818-365-6321 F/T 1 (TA, PE, SP, AM)Tooth Fairy Dental #002380556 S Brand Blvd 818-365-3004 F/T 1 (SP, TA)SAN GABRIELAnthony Cheing, DDS #0217755204 Rosemead Blvd 626-286-2111 F/T 1 (CA, CH, SP, VI, PE, TA, HI) U

Del Mar Family Dental #001455702 S Del Mar Ave Ste A 626-287-9781 P/T 1 (AR, SP) U

Dr. M Lwin #0014571739 S San Gabriel Blvd 626-288-5777 P/T 2 (CA, CH, SP)Hong Sun, DDS #0023786951 Rosemead Blvd 626-292-5865 F/T 1 (SP, CH) U

Las Tunas Family Dental #3719011107 E Las Tunas Dr 626-285-0031 P/T 1 (CH, SP) U

San Gabriel Dental Group #0239026909 Rosemead Blvd 626-286-8600 P/T 2 (CH, SP, CA) U

San Gabriel Family Dentistry #001807531 W Las Tunas Dr Ste B 626-281-1628 F/T 1 P/T 1 (SP, CH, VI) U

San Gabriel Valley Family Dtl #0133136503 Rosemead Blvd 626-286-2156 F/T 1 (CA, CH, FR, RU, SP, TA) U

Sun Dental #1766011720 S San Gabriel Blvd 626-288-9055 F/T 1 (CH, SP) U

Thomas Wu, DDS #0C35011103 S San Gabriel Blvd # A 626-286-7000 F/T 1 (CA, CH, TA, SP, HI, PE, AM) U

SAN JACINTOEsplanade Dental #0261672191 W Esplanade Ave # F106 951-487-2999 P/T 1 (VI, TA, SP) U

San Jacinto Dental Group #009003701 W Esplanade Ave Ste K L 951-654-3424 P/T 1San Jacinto Smiles #0248441821 S San Jacinto Ave D 951-654-7744 P/T 1 (SP) U

SAN JUAN CAPISTRANOCapistrano Dental Partnership #02893631878 Del Obispo St Ste 105 949-487-3273F/T 2 (AR, SP)Jeffrey Jacobson, DMD #01654532183 Camino Capistrano 949-489-1013 F/T 1 (SP) U

Mehrvarzi Mehrdokht Dtl Corp #0C970131952 Camino Cpstrno C14 C16 949-240-6888 F/T 1 (SP, TA)Ortega Dental Center #02817331726 Rancho Viejo Rd # B109 949-240-0250 P/T 1 U

RW Implant & Cosmetic Dentistry #03061831654 Rancho Viejo Rd # I- 1 949-240-4337 F/T 2 (SP) U

San Juan Dental Group #01358731897 Del Obispo St Ste 100 949-487-0284 F/T 1 (VI, SP)SAN LUIS OBISPODisbell Mansilla, DDS #0075741551 Bishop St Ste 420 805-547-7010 F/T 2 (AR, CH, KO, PE, SP, TA, VI)Mission Family Dental #0336694251 S Higuera St Ste 502 805-540-5251 F/T 1 (SP)Ricuccio Negom, DDS #032053735 Tank Farm Rd Ste 170 805-549-9000 P/T 1 (IT)SAN MARCOSAnna Durkin, DDS #0035321344 E Mission Rd Ste C 760-740-0070 F/T 1 (FR, RU, SP)Bright Now! Dental San Marcos #03358752 S Rancho Santa Fe Rd 760-936-0002 F/T 1 P/T 5 (SP)Grand Plaza Dental Group #024235137 S Las Posas Rd Ste 250 760-752-7000 F/T 1 (SP) U

San Elijo Dental #0280981691 Melrose Dr Ste 160 760-798-0828 P/T 1 (PE, SP) U

San Marcos Dental Group #009368709 Center Dr Ste 101 760-746-2045 P/T 2Smart Dental #031325960 W Sn Mrcos Blvd Ste 120 760-471-8800 P/T 1 (AR, SP, TA) U

Smiles of Lake San Marcos #0333911635 Lake San Marcos Dr # 10 760-591-3450 P/T 1 (SP) U

Smiles of San Marcos #023810630 Nordahl Rd Ste D 760-480-1750 F/T 1 (HI, TA) U

Sun Smile Dental Group #0137141582 W Sn Mrcos Blvd Ste 201 760-744-1300 F/T 1 (SP)Woodland Dental Group #019237979 Woodland Pkwy Ste 100 760-745-1100 P/T 1 (SP, PE) U

SAN PEDROHamid Cohen-Kheradyar, DDS #3C8301138 S Gaffey St 310-514-9100 F/T 1 (SP, PE)Milena Tasic, DDS #396501601 W 6Th St 310-831-1211 F/T 1 (GE) U

San Pedro Dental #019925697 S Gaffey St 310-548-1273 F/T 4 P/T 6 (SP) U

SANTA ANAAll Star Dental & Braces #026173940 N Grand Ave 714-541-9494 P/T 2 (PE, SP) U

Andrew Shieh, DDS #0120741028 W 1St St Ste E 714-542-5421 P/T 1 (CH, SP) U

Barba Dental Corp #0299572010 E 1St St Ste 250 714-558-6949 F/T 1Bay Dental #1605013620 S Bristol St Ste 307 714-540-2836 F/T 1 (SP, PE, VI) U

Bright Smile Dental #023242642 S Harbor Blvd 714-775-0202 F/T 1 (VI, SP, HI) U

Bristol Dental & Orthodontics #0309402502 S Bristol St 714-754-1888 F/T 1Dental 4 #013085102 E 4Th St Fl 2 714-558-1464 F/T 1 (SP)Family Dental #026080516 A West 17th Street 714-972-2506 F/T 1Friendly Smile Dental #0261641521 N Broadway 714-972-2801 F/T 1 (SP) U

Geeta Seth, DDS #0220991120 W Warner Ave Ste C 714-556-4740 F/T 1 (SP, HI) U

Iraj Ebrami, DDS #3771011125 E 17th St Ste E227 714-543-7770 P/T 1 (PE, SP)Kenneth Kim DDS A Prof Corp #0221062723 N Bristol St Ste D2 714-550-0006 P/T 1 (SP, KO) U

Louis Cohen, DDS #0C52011913 E 17th St Ste 113 714-547-9751 F/T 1 (SP)Nandini Murthy, DDS #0073332723 N Bristol St Ste D7 714-569-0021 P/T 1 (SP)Oasis Dental Santa Ana #027159408 W 4th St 714-836-9999 F/T 1 (SP, CH) U

Orange Coast Dental #0221401717 Old Tustin Ave 714-835-9188 F/T 1 (SP, PE)Pinnacle Dental Group #01287631 E Macarthur Cres Ste 109 714-549-1248 F/T 1 (PE, SP) U

Prakash Patel, DDS #0130872637 N Grand Ave 714-288-9980 P/T 1 (HI, SP) U

Santa Ana Dental #0214061631 N Bristol St Ste 100 714-567-9255 F/T 4 P/T 11 (SP) U

Shui Dental #0139931702 S Main St 714-796-9253 F/T 1 (SP, CH) U

Smilecare Dental Group #0134511718 N Main St 714-543-0600 P/T 4 (SP) U

Smilecare-South Coast #0039633500 S Bristol St Ste 100 714-957-6030 F/T 4 P/T 4 (SP) U

South Coast Dental Group #0130672231 S Bristol St 714-556-1001 F/T 2 (SP) U

South Coast Family Dental #0335542781 W Macarthur Blvd Ste N 714-556-7277 F/T 1 (PE, SP) U

Sweet Tooth Dental #030578301 1/2 N Main St 714-547-6600 P/T 2 (SP) U

United Dental Care #0147961710 E 17Th St Ste E 714-564-9000 P/T 1 (AR, SP)Universal Care Dental #1C02011400 N Main St 714-480-0434 F/T 3 P/T 4 (SP, VI) U

SANTA BARBARADennis Dierenfield, DDS #2C400116 W Mission St Ste A 805-569-2338 F/T 1 (SP)Gentle Dental Sta. Barbara #009433330 State St Ste A 805-963-1533 F/T 1 P/T 1 U

Sea Breeze Dental/Dr Zak #0C67015168 Hollister Ave Ste A 805-683-5300 F/T 1 P/T 2 (SP) U

SANTA CLARITABright Now Dental #02274926477-81 Golden Valley 661-253-1010 F/T 2 P/T 9 (SP) U

Dmitry G Aminov DMD #03348526781 Bouquest Cyn Rd 661-513-0655 P/T 1 (RU) U

Golden Triangle Dental #03414121700W Golden Triangle#201 661-259-5540 P/T 2 (AR, PE, SP)Valencia Dental Group #01641828134 Newhall Ranch Rd 661-607-0202 P/T 2 (SP) U

Zak Dental Care #13110126324 Bouquet Canyon Rd 661-253-4000 P/T 2 (RU, SP, PE, HI) U

SANTA FE SPRINGSSanta Fe Dental #00223910009 Orr and Day Rd 562-484-0808 F/T 1 (SP)SANTA MARIAFriendly Smiles Dental Group #0131622528 S Broadway Ste C 805-928-6776 F/T 2 (AM, CH, PE, SP, TA) U

SANTA MONICAAmerican Dental Center #0264911244 7th St Ste 204 310-394-3942 F/T 1 (PE, FR, GE, SP)American Family Dtl Office #0117052210 Santa Monica Blvd Ste B 310-264-5084 F/T 1 (SP, PE, HE, AR, GE, TA)Artistic Center For Dentistry #0318501531 6th St Apt 100 310-393-2300 F/T 1 (PE, TA) U

Douglas Oswell, DDS #0047013231 Pico Blvd 310-828-7429 F/T 3 P/T 1 (SP)Field And Field DDS #2004011807 Wilshire Blvd Ste A 310-453-5436 F/T 2 (SP) U

Santa Monica Dental #0C98011244 7th St Ste 101 310-393-0743 F/T 1 (SP)Super Dental Care #0130603200 Sta Mon Blvd Ste 204 310-453-8907 F/T 1 (SP, PE)Whiter & Brighter Dental #0120723201 Wilshire Blvd Ste 110 310-829-5181 P/T 2 (JA) U

Yosi Behroozan, DDS #0258712221 Lincoln Blvd Ste 200 310-399-1100 F/T 2Yvonne Goff, DDS #0328401304 15th St Ste 403 310-458-0800 P/T 1 U

SANTEEEdward Reidy, DDS #2195019280 Mast Blvd 619-449-8530 F/T 1Santee Cottonwood Dental #0218399715 Mission Gorge Rd 619-448-7444 P/T 2 (PE, SP, TA, RU)Santee Town Center Dental Grp #023560246 Town Center Pkwy 619-312-6006 P/T 2 (SP) U

Towne Center Dental Group #0064219862 Mission Gorge Rd Ste E 619-596-1600 P/T 2 (Sp)SAUGUSBouquet Smile Dental #01506128100 Bqt Cyn Rd Ste 200 661-263-6923 P/T 1 (VI) U


D0100-D0999 DIAGNOSTICClinical oral evaluationsD0120 Periodic oral evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.00D0140 Limited oral evaluation — problem focused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.20D0150 Comprehensive oral evaluation — new or established patient . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.20D0160 Detailed and extensive oral evaluation, problem focused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.00 D0170 Reevaluation limited problem focused (established patient; not post operative visit). . . . . . . . . . 21.00 D0180 Comprehensive periodontal evaluation — new or established patient . . . . . . . . . . . . . . . . . . . . . 21.00

Radiographs/diagnostic imaging (including interpretation)D0210 Intraoral — complete series including bitewings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54.00D0220 Intraoral periapical — first film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.00D0230 Intraoral periapical — each additional film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.00D0240 Intraoral — occlusal film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.00D0250 Extraoral — first film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.00D0260 Extraoral — each additional film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.00D0270 Bitewing — single film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.00D0272 Bitewings — two films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.00D0274 Bitewings — four films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.00D0277 Vertical bitewings — 7 to 8 films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.00D0290 Posterior — anterior or lateral skull and facial bone survey film . . . . . . . . . . . . . . . . . . . . . . . . . . 19.00D0330 Panoramic film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.00D0340 Cephalometric film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.00

Oral pathology laboratoryD0472 Accession of tissue, gross exam, preparation and transmission of written report. . . . . . . . . . . . . 59.00D0473 Accession of tissue, gross & microscopic exam, preparation and transmission of written report. . . . . 59.00D0474 Accession of tissue, gross & micro exam, assessment of surgical margins for presence of disease, preparation and transmission of written report . . . . . . . . . . . . . . . . . . . . . . 59.00

D1000-D1999 II. PREVENTIVEDental prophylaxisD1110 Prophylaxis — adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.20D1120 Prophylaxis — child through age 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.60

Topical fluoride treatmentD1201 Topical application of fluoride (including prophylaxis) — child through age 13 . . . . . . . . . . . . . . . 38.40D1203 Topical application of fluoride (prophylaxis not included) — child through age 13 . . . . . . . . . . . . 13.20D1204 Topical application of fluoride (prophylaxis not included) — adult. . . . . . . . . . . . . . . . . . . . . . . . . 10.80D1205 Topical application of fluoride (including prophylaxis) — adult . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.60

Other preventive servicesD1351 Sealant— per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.00D1352 Preventive resin restoration — per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.00

Space maintenance (passive appliances) (including all adjustments within six months following installation).D1510 Space maintainer — fixed — unilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115.00D1515 Space maintainer — fixed — bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.00D1520 Space maintainer — removable — unilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143.00D1525 Space maintainer — removable — bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187.00

D2000-D2999 III. RESTORATIVE – Procedures subject to 6 month waiting periodAmalgam restorations (including polishing)D2140 Amalgam — one surface, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.00D2150 Amalgam — two surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.00D2160 Amalgam — three surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.00D2161 Amalgam — four or more surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58.00

Resin — based composite restorations — directD2330 Resin-based composite — one surface, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.00D2331 Resin-based composite — two surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.00D2332 Resin-based composite — three surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.00D2335 Resin-based composite — four or more surfaces or involving incisal angle (anterior) . . . . . . . . . . . 68.00D2390 Resin-based composite crown, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.00D2391 Resin-based composite — one surface, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47.00D2392 Resin-based composite — two surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64.00D2393 Resin-based composite — three surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00D2394 Resin-based composite — four or more surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00

Inlay/onlay restorationsD2510 Inlay — metallic — one surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99.00D2520 Inlay — metallic — two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.00D2530 Inlay — metallic — three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.00D2542 Onlay — metallic — two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.00D2543 Onlay — metallic — three surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.00D2544 Onlay — metallic — four or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.00D2650 Inlay — resin-based composite — one surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34.00D2651 Inlay — resin-based composite — two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00D2652 Inlay — resin-based composite — three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63.00

Crowns — single restoration onlyD2710 Crown — resin (indirect) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00D2712 Crown — 3/4 resin-based composite indirect) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00D2720 Crown — resin with high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182.00D2721 Crown — resin with predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.00D2722 Crown — resin with noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177.00D2740 Crown — porcelain/ceramic substrate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192.00D2750 Crown — porcelain fused to high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182.00D2751 Crown — porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.00D2752 Crown — porcelain fused to noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177.00D2780 Crown — 3/4 cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186.00D2781 Crown — 3/4 cast predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186.00D2782 Crown — 3/4 cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186.00D2790 Crown — full cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183.00D2791 Crown — full cast predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170.00D2792 Crown — full cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178.00D2794 Crown — titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183.00

Other restorative servicesD2910 Re-cement inlay, onlay, or partial coverage restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.00D2915 Re-cement cast or prefabricated post and core. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.00D2920 Re-cement crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.00D2930 Prefabricated stainless steel crown — primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65.00D2931 Prefabricated stainless steel crown — permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74.00

D2932 Prefabricated resin crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00D2933 Prefabricated stainless steel crown with resin window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.00D2934 Prefabricated esthetic coated stainless steel crown — primary tooth . . . . . . . . . . . . . . . . . . . . . 90.00D2950 Core buildup, including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.00D2951 Pin retention — per tooth, in addition to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.00D2952 Cast post and core in addition to crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.00D2954 Prefabricated post and core in addition to crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.00D2960 Labial veneer (resin laminate) — chairside. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116.00D2961 Labial veneer (resin laminate) — laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128.00D2962 Labial veneer (porcelain laminate) — laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161.00D2980 Crown repair, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00

D3000-D3999 ENDODONTICS – Procedures subject to 6 month waiting periodPulpotomyD3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to the dentinocemental junction and application of medicament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.00D3230 Pulpal therapy (resorbable filling) — anterior, primary tooth (excluding final restoration) . . . . . . 38.00D3240 Pulpal therapy (resorbable filling) — posterior, primary tooth (excluding final restoration). . . . . . 38.00

Procedures D3310 through D3450 include all test x-rays taken as part of the complete root canal procedure.

Endodontic therapy (including treatment plan, clinical procedures, and follow-up care).D3310 Anterior (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193.00D3320 Bicuspid (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227.00D3330 Molar (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306.00D3346 Retreatment of previous root canal therapy — anterior . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 193.00D3347 Retreatment of previous root canal therapy — bicuspid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227.00D3348 Retreatment of previous root canal therapy — molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306.00D3351 Apexification/recalcification/pulpal — initial visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.00D3352 Apexification/recalcification/pulpal regeneration — interim medication replacement . . . . . . . . . . 56.00D3353 Apexification/recalcification — final visit (includes completed root canal therapy — apical closure/calcific repair of perforations, root resorption, etc .) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.00

Apicoectomy/periradicular servicesD3410 Apicoectomy/periradicular surgery — anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240.00D3421 Apicoectomy/periradicular surgery — bicuspid (first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257.00D3425 Apicoectomy/periradicular surgery — molar (first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294.00D3426 Apicoectomy/periradicular surgery (each additional root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00D3430 Retrograde filling — per root. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57.00D3450 Root amputation — per root . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166.00

Other endodontic servicesD3920 Hemisection (including any root removal), not including root canal therapy . . . . . . . . . . . . . . . . . 121.00

D4000-D4999 V. PERIODONTICS – Procedures subject to 6 month waiting periodSurgical services (including usual postoperative services)D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or bounded teeth spaces per quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128.00D4211 Gingivectomy or gingivoplasty — one to three contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77.00D4240 Gingival flap procedure, including root planing — four or more contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.00D4241 Gingival flap procedure, including root planing — one to three contiguous teeth or bounded . . . teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95.00D4245 Apically positioned flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.00D4249 Clinical crown lengthening — hard tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96.00D4260 Osseous surgery (including flap entry and closure) — four or more contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342.00D4261 Osseous surgery (including flap entry and closure) — one to three contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205.00D4263 Bone replacement graft — first site in quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62.00D4264 Bone replacement graft — each additional site in quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47.00D4266 Guided tissue regeneration — resorbable barrier, per site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D4267 Guided tissue regeneration — non-resorbable barrier, per site (includes membrane removal) . . . . 135.00D4270 Pedicle soft tissue graft procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192.00D4271 Free soft tissue graft procedure (including donor site urgery) . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 208.00D4273 Subepithelial connective tissue graft procedures, per tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233.00

Non-surgical periodontal serviceD4341 Periodontal scaling and root planing — four or more teeth per quadrant . . . . . . . . . . . . . . . . . . . 59.00D4342 Periodontal scaling and root planing — one to three teeth, per quadrant . . . . . . . . . . . .. . . . . . . 35.00D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis . . . . . . . . . . . . . . . . 36.00

Other periodontal servicesD4910 Periodontal maintenance (following active therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.00D4920 Unscheduled dressing change (by someone other than treating dentist) . . . . . . . . . . . . . . . . . . . . 36.00

D5000-D5999 IV. PROSTHODONTICS REMOVABLE – Procedures subject to 12 month waiting periodProcedures relating to dentures, partial dentures and relines include adjustments for a six month period following installation. Such procedures do not include specialized techniques involving precision dentures, personalizationor characterizations.

Complete dentures (including routine post-delivery care)D5110 Complete denture — maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240.00D5120 Complete denture — mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241.00D5130 Immediate denture — maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240.00D5140 Immediate denture — mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241.00

Partial dentures (including routine post-delivery care)D5211 Maxillary partial denture — resin base (including conventional clasps, rests and teeth) . . . . . . . 203.00D5212 Mandibular partial denture — resin base (including any conventional clasps, rests and teeth). . . . . . 212.00D5213 Maxillary partial denture — cast metal framework with resin denture bases (including conventional clasps, rests and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287.00D5214 Mandibular partial denture — cast metal framework with resin denture bases (including . . . . . conventional clasps, rests and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287.00D5225 Maxillary partial denture — flexible base (including any clasps, rests and teeth) . . . . . . . . . . . . 216.00D5226 Mandibular partial denture — flexible base (including any clasps, rests and teeth) . . . .. . . . . . . 216.00D5281 Removable unilateral partial denture — one piece cast metal (including clasps and teeth). . . . . 120.00

Code Description Allowance Code Description Allowance

KPIC Dental Insurance Plan 2011 Table of AllowancesThe benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under the Delta Dental program and is not to be interpreted as CDT-2011 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.

4 33Revisions to the Current Dental Terminology (CDT) Codes may not have been reflected in the above Table of Allowances. Please refer to your Certificate of Insurance for the updated Table of Allowances.

Yong Jun Park, DDS #02815412307 Poway Rd Ste B 858-668-3390 F/T 1 (SP, KO) U

RANCHO CUCAMONGAAnthony Kavorinos, DDS #05310110630 Town Center Dr Ste 131 909-987-6643 F/T 1 P/T 1 U

Bright Now! Dental #01484111561 Foothill Blvd Ste 104 909-483-7811 F/T 6 P/T 17 (SP) U

Dentistry By Dr Doshi & Assoc #0195007379 Milliken Ave Ste 110 909-945-3355 P/T 1 (SP) U

Dr Hattar Dental #0262439950 Foothill Blvd Ste T 909-980-4816 P/T 2 (AR, SP)Ghazal Dental Corporation #3C700110797 Foothill Blvd 909-581-0888 P/T 1Gina Barrameda, DMD #0185208351 Rochester Ave Ste 109 909-466-5352 P/T 2 (SP, TA) U

Grove Dental Group #0251798283 Grove Ave Ste 208 909-291-8625 F/T 1 (AM, RU, SP)Horizons Dentistry #0337939353 Fairway View Pl# 200 909-987-9933 F/T 1 P/T 1 (AR, SP) U

Jeffrey Lloyd, DDS #3591019310 Baseline Rd 909-989-1868 F/T 1 (JA, SP)Milliken Family Dentistry #0305299635 Milliken Ave 909-481-8990 F/T 1 (AR, SP) U

Monet Dental Group #02288612455 Victoria Grdns Ln 190 909-646-3057 P/T 2 (SP, TA) U

Oasis Dental #02953010801 Foothill Blvd Suite 10 909-941-2288 F/T 1 (TA, SP) U

Rancho Cucamonga Dental Care #39030110470 Foothill Blvd Ste 126 909-989-7888 F/T 1 (SP) U

Rania Refaat, DDS #1C74017388 Carnelian St Ste C 909-989-1758 F/T 1 (AR, SP) U

Renaissance Dental Care #0269329080 Milliken Ave Ste 100 909-987-0040 P/T 1Smilecare-Rancho Cucamonga #003966 9349 Foothill Blvd Ste B 909-980-6363 F/T 1 P/T 4 (SP)Star Dental Group #11770112729 Foothill Blvd Ste A 909-899-8757 F/T 3 (PE, SP)Upland Dental and Ortho #01293511328 Kenyon Way 909-945-5800 P/T 2 (VI, SP, Ch) U

Winery Estate Dental Group #0141157369 Day Creek Blvd # F-103 909-646-7902 P/T 2 (SP, VI) U

RANCHO MIRAGE Rancho Mirage Dental Group #02286272-027 Highway 111 #C 760-340-5155 P/T 2 (SP) U

RANCHO SANTA MARGARITAAppealing Dentistry #00840629839 Snta Mrgrita Pkwy 100 949-766-7687 P/T 1 (AR, HE, RU, SP) U

Elite Dentistry #01457022391 Antonio Pkwy Ste J200 949-888-8989 F/T 1 (CH, VI) U

Rancho Dental Group #3C650130592 Santa Margarita Pkwy 949-766-5740 P/T 1 (SP)Robert Murray, DDS #02608322032 El Paseo Ste 230 949-713-1606 P/T 1Santa Margarita Dtl Grp #01530722195 El Paseo Ste 260 949-459-9300 P/T 2 (PE, SP, TA)So Cal Smiles Dentistry #01383222195 El Paseo Ste 220 949-766-0006 P/T 1 (AR, RU, SP, TA)REDLANDSBeautiful Smile Dental Center #0305801895 Orange Tree Ln Ste 103 909-307-6453 F/T 1 (JA, SP)Bright Now Dental #0160121285 Alabama St Ste D 909-793-5777 F/T 5 P/T 7 (SP) U

Brookside Dental Associates #155201720 Brookside Ave Ste 100 909-798-7111 F/T 1 (SP) U

Drs Low & Li #301601229 Cajon St 909-792-9217 F/T 2 (CH, SP) U

Elite Dental Associates #028395245 Terracina Blvd Ste 207A 909-798-4111 F/T 1 U

Orange Plaza Dentistry #114501470 Orange St 909-793-4585 F/T 1 (CH, SP) U

Pavillion Smile Dental #0291462094 W Redlands Blvd Ste F 909-792-0500 F/T 1 (TA, SP)Redlands Dental Associates #012341860 W Redlands Blvd 909-793-5270 P/T 1 (RU, SP) U

Redlands Dental Group #005437 422 Orange St 909-792-7500 P/T 1 U

United Dental Group #018236434 Cajon St Ste 101 909-793-8793 F/T 2 P/T 5 (SP)REDONDO BEACHBarry Kashfian Dental Group #2700011917 S Catalina Ave # B 310-375-0787 P/T 1 (SP, PE)Bayside Dental Care #0214371884 1/2 S Pacific Coast Hwy 310-792-4627 F/T 1 P/T 1 (SP, HI)Dental Ctr of Redondo Beach #0027831959 Kingsdale Ave 310-921-3938 P/T 1 (AM, AR, PE, SP) U

Galleria Dental Care #1266012772 Artesia Blvd Ste 103 310-370-1586 F/T 2 (FR, IT, SP, PE) U

Redondo Beach Dental Arts #0057722731 Manhattan Beach Blvd 310-643-0880 F/T 1 P/T 1 (PE, SP)RESEDAAdult And Kids Dental #0299546915 Reseda Blvd Unit 6 818-881-6761 F/T 1Affinity Dental Group #0167376650 Reseda Blvd Ste 101B 818-705-7645 P/T 1 (PE, SP) U

Canby Dental #00166818440 Sherman Way 818-343-4024 P/T 1 (PE, SP) U

Citi Dental #0192596900 Reseda Blvd Ste C 818-705-0200 F/T 1 (PE, SP)City Dental Group #02870918511 Sherman Way 818-345-9800 F/T 1Columbus Dental Group #00403218305 Sherman Way # 7 818-996-9200 F/T 1 (SP) U

Esthetic Smile #02651419231 Victory Blvd Ste 216 818-344-4929 F/T 1Harvey Dlugatch, DDS #09290118909 Sherman Way Frnt 818-345-1343 F/T 1 (SP)Henide Arias, DDS #02718019231 Victory Blvd Ste 252 818-881-8940 P/T 1James Zarrinnegar, DDS #02311719231 Victory Blvd Ste 357 818-344-0177 P/T 2John Foroutan, DDS #00275418308 Sherman Way Ste 1 818-881-0404 F/T 1 (SP) U

Linda Kapgan, DDS #32540119301 Saticoy St Ste D 818-772-4222 P/T 1 (RU, SP) U

Reseda Dental Group #01398718437 Saticoy St Ste 1 818-344-8338 F/T 1 (AM, PE, SP, TA, TR)Reseda Dental Office #02459118554 Sherman Way 818-708-9919 F/T 1 (SP, RU, AM)Reseda Village Dental Studio #02911818700 Sherman Way Ste 116 818-757-7070 F/T 1 (SP, VI) U

San Fernando Valley Dtl Group #01925819231 Victory Blvd Ste 458 818-345-6477 P/T 1 (PE, TA)

Smile Masters Dental Center #00448017703 Vanowen St 818-609-0009 F/T 1 (SP, VI, PE, HI) U

RIALTOCare Family Dental #0129762836 W Rialto Ave Ste A 909-820-9454 F/T 1 (KO, SP)Dental Care Of Rialto Inc #1660011817 N Riverside Ave 909-879-1024 F/T 3 (CH, HI, SP)Designer Dentistry Rialto #0228021786 N Riverside Ave Ste 5 909-874-0323 F/T 4 P/T 3 (AR, PE, SP)Dr Ahuja and Dr Gill’s Dental #015811224 E Base Line Rd 909-874-4699 P/T 2 (SP, HI) U

Dr Ahujas Dental Office #0001311130 N Riverside Ave 909-873-0277 P/T 1 (SP) U

Family Dentistry #117501511 S Riverside Ave 909-820-2274 F/T 1 P/T 1 (SP)Family Dentistry #0228871734 N Riverside Ave Ste 3 909-875-1279 F/T 1 (CH, IN, SP)Paulette Newman, DDS #0113081733 N Riverside Ave 909-875-2548 F/T 1 U

Rialto Dental Group #0045141629 S Riverside Ave 909-421-2225 P/T 2 (SP) U

Samir Shah, DDS #022890469 W Base Line Rd 909-746-0444 F/T 1 (HI, SP)Tri Star Family Dental Center #000011106 N Eucalyptus Ave 909-875-1299 F/T 1 (SP, VI)RIVERSIDEAllan Etemadi, DDS #0001616071 Magnolia Ave 951-680-1777 F/T 2 (PE, SP)Anwar Nasser, DDS #0177766326 Mission Blvd Ste B 951-367-1666 F/T 1 (AR, SP)Arlington Dental #2C02013297 Arlington Ave Ste 101 951-683-6055 P/T 2 (SP)Arlington Family Dental #0147946160 Arlington Ave Ste D4 951-637-0013 F/T 1 (AM, SP)Arsen Sukiasyan, DDS #0176327000 Indiana Ave Ste 117 951-367-1345 P/T 1 (SP, RU, AM) U

CA Dental Grp of Riverside #0281583845 Pierce St Ste A 951-359-1900 F/T 1 P/T 1 (SP)Canyon Springs Dtl Grp #0155842878 Campus Pkwy Ste C-1 951-571-0011 F/T 1 P/T 1 (SP) U

Community Dental of Dr Chi #0035204595 La Sierra Ave 951-688-6000 P/T 1 (CH, KO, SP)Dental Assoc of Riverside #2675013487 Central Ave 951-369-1001 P/T 2 (SP)Dental Health Riverside #0271256339 Brockton Ave 951-369-3597 F/T 2Family Dentistry #0129514710 La Sierra Ave 951-324-8180 F/T 1 (SP)Gateway Dental Group #01433810286 Indiana Ave 951-359-5200 F/T 1 P/T 3 (SP, TA, VI) U

Gentle Dental- Riverside #00698310168 Indiana Ave 951-352-9747 F/T 2 P/T 2 U

Gentle Dental-Riverside #0069763630 Central Ave Ste 6 951-682-1720 F/T 2 P/T 2 (AR, SP) U

Grove Dental Group #0141418735 Trautwein Rd 951-776-1330 P/T 1 U

Hoang Nguyen, DDSInc #0106327120 Indiana Ave Ste B 951-276-2877 P/T 1 (SP, VI)Inner Brightness Dental #0316346165 Valley Springs Pkwy # E 951-214-6585 F/T 1

Julia Fundeanu, DDS., Inc #0106316860 Brockton Ave Ste 12 951-684-9917 F/T 1 (GE, SP, RO)La Sierra Family Dentistry #1523013410 La Sierra Ave Ste D 951-354-9550 F/T 1 (JA, KO, SP, GE, RO) U

Low Family Dentistry #0806016862 Palm Ave 951-683-5490 F/T 1 (SP)M J Savani, DDS #2073014080 Tyler St Ste D 951-359-0149 F/T 1 (SP, HI)Newport Dental #0007673724 La Sierra Ave Ste F1 951-688-2400 F/T 2 P/T 21 (SP)Newport Dental #0054653560 Arlington Ave 951-680-1200 F/T 5 P/T 19 (SP)Norma Vazquez, DDS #0324494060 Madison St 951-352-0500 F/T 1 (SP) U

Orangecrest Fmly Dtl Practice #02465119348 Van Buren Blvd Ste 117 951-789-9905 F/T 1 (PE, SP) U

Parissa Djafari, DDS #0127186900 Brockton Ave Ste 2 951-682-2245 F/T 1 P/T 1 (FR, PE, SP)Regal Dentistry #0256213950 Pierce St Ste L 951-688-0082 F/T 1 (SP)Reza Rajabi, DMD #0142437776 Limonite Ave 951-360-0696 F/T 1 P/T 1 (PE, SP, TA)Riverside Dental Office #0266121485 University Ave 951-784-4441 F/T 1Riverside Dentistry #1211011857 University Ave 951-781-3021 F/T 1 P/T 1 (SP, VI)Riverwalk Dental Spa #00776911695 Slate Ave Ste 200 951-353-0050 F/T 1 P/T 1 (SP) U

Smile Builder #021534473 E Alessandro Blvd # A 951-789-6886 P/T 1 (SP, CH) U

Smilecare-Riverside #00422110001 Indiana Ave 951-689-0701 F/T 3 P/T 4 (SP)Suraj Pal Sharma DDS., Inc #0117775515 Van Buren Blvd 951-352-5838 F/T 1 (SP, HI)Universal Care Dental #1C07014024 12th St 951-784-0636 F/T 7 P/T 3 (SP, TA, VI)West Coast Dental Group #0217033380 La Sierra Ave Ste 108 951-354-9999 P/T 1 U

ROSEMEADGlenrose Dental Group #0078938951 Glendon Way 626-288-7667 P/T 2 (CH, SP, TA)Min Lwin, DDS #0017058038 Garvey Ave Ste B 626-571-7000 P/T 2 (CA, CH, SP) U

Rosemead Family Dental Center #0162317556 Garvey Ave 626-573-2000 P/T 1 (SP, CH)Sethi Family Dental Center #0031332111 San Gabriel Blvd Ste I 626-280-4976 F/T 1 (SP) U

Smilecare-Rosemead #0035134100 Rosemead Blvd 626-575-1161 P/T 6 (SP)Steven Hou, DDS #0024962240 San Gabriel Blvd 626-288-8357 F/T 1 (CH, SP) U

ROWLAND HEIGHTSGrace Dental Care #02036417827 Colima Rd 626-965-7888 F/T 1 (KO, SP) U

Plaza Dental Group #26850118156 Colima Rd 626-965-0971 F/T 2 (SP, CH, KO) U

Smilecare-Puente Hills #00351118025 Gale Ave 626-965-2500 P/T 3 (SP)Steven Chiu, DDSInc #01259418906 Gale Ave Ste B 626-965-5618F/T 1 (CH)

Valley Dental Center #00541817595 Almahurst St Ste 101-2 626-965-7445 F/T 2 (SP, TA, VI) U

SAN BERNARDINOAhmed Naji, DDS #0153051799 N Waterman Ave Ste E 909-883-8282 P/T 1 (AR, SP)Alejandra Galindo-Magallanes #010256740 W 3Rd St 909-888-3688 P/T 1 (SP)Aloha Dental Practice #0182031799 N Waterman Ave Ste D 909-882-3745 P/T 1Arrowhead Family Dentistry #011183407 S E St 909-889-3300 F/T 2 P/T 7 (HI, SP)Brenda Evans-Louka, DDS #1935011848 Commerce Center East 909-382-0255 F/T 1 (AR, SP, FR) U

Citrus Dental #193801242 E Airport Dr Ste 100 909-890-0050 F/T 1 (SP) U

D Street Dental Group #2843011579-81 North “D” St 909-889-1977 F/T 1 (KO, SP)Dr Gill’s Family Dentistry #0292971584 W Base Line St Ste 103 909-885-3100 P/T 4 (SP)Hoang Nguyen, DDS #0110071918 Business Cntr Dr # 210 951-276-2877 P/T 1 (SP, VI)Hovsep Nargizyan, DDS #0109041655 N Mount Vernon Ave # B 909-885-8707 P/T 1 (SP, TA, AM, RU, VI, KO)Hub Plaza Dental Group #0127441047 Harriman Pl Ste B 909-796-6700 P/T 2 (GE, SP) U

Ian Shwartzman, DDS #0153062130 N Arrowhead Ave Ste 207 909-475-5565 P/T 1 (RU, SP)Inland Dental Center #1C7601599 Inland Center Dr Ste 116 909-384-1111 F/T 2 P/T 3 (KO, SP) U

Luis Vargas, DDS #000217965 S E St Ste N 909-885-6262 F/T 1 (CH, SP)Mgo Dental.Com #025852654 W 4th St # A 909-386-3650 P/T 2 (SP, TA, AR, FR) U

San Bernardino Dental Group #000129575 W 5th St 909-888-6581 F/T 2 P/T 2 (KO, SP)Sierra Gateway Dental Office #0133124168 N Sierra Way 909-886-8900 P/T 1 HI, VI U

Southland Dental Group #007367399 E Highland Ave Ste 120 909-881-0645 F/T 2 (SP)Sure Smile Dental Office #011723275 E 9Th St Ste L 909-381-5555 F/T 1 P/T 2 (SP, HI)Waterman Dental Center #3964011428 N Waterman Ave Ste A 909-889-1111 F/T 1 (SP) U

Wildwood Dental Group #0321243972 N Waterman Ave Ste 110 909-886-4864 F/T 1 P/T 1 (HI) U

SAN CLEMENTEAesthetic Dental Associates #0224681161 Puerta Del Sol 100 949-218-0433 F/T 1 (SP) U

Artistic Dentistry #012354439 N El Camino Real Ste E 949-366-1177 F/T 1 (PE, SP) U

Brighter Image Dental #0138441031 Avenida Pico Ste 203 949-361-6900 P/T 1 (SP, KO) U

San Clemente Dental Group #004795943 Avenida Pico Unit A 949-366-9555 P/T 2 (SP, TA, VI) U

San Clemente Dtl Associates #012873638 Camino De Los Mares C140 949-234-0500 F/T 2 (RU, RO, AR, SP, HE) U

Talega Dental Group #0090351151 Puerta Del Sol Ste A 949-369-8300 P/T 1 (PE, SP) U

SAN DIEGOAdvanced Dentistry #0233054320 Genesee Ave Ste 101 858-277-8100 P/T 1 (SP) U


32 5

Adjustments to denturesD5410 Adjust complete denture — maxillary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.00D5411 Adjust complete denture — mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.00D5421 Adjust partial denture — maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.00D5422 Adjust partial denture — mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.00

Repairs to complete denturesD5510 Repair broken complete denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.00D5520 Replace missing or broken teeth — complete denture (each tooth) . . . . . . . . . . . . . . . . . . . . . . . 25 .00

Repairs to partial denturesD5610 Repair resin denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.00D5620 Repair cast framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00D5630 Repair or replace broken clasp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.00D5640 Replace broken teeth — per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.00D5650 Add tooth to existing partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.00D5660 Add clasp to existing partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.00

Denture rebase proceduresD5710 Rebase complete maxillary denture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.00D5711 Rebase complete mandibular denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.00D5720 Rebase maxillary partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89.00D5721 Rebase mandibular partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.00

Denture reline proceduresD5730 Reline complete maxillary denture (chairside). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.00D5731 Reline complete mandibular denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.00D5740 Reline maxillary partial denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.00D5741 Reline mandibular partial denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47.00D5750 Reline complete maxillary denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 70.00D5751 Reline complete mandibular denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70.00D5760 Reline maxillary partial denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.00D5761 Reline mandibular partial denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.00

Interim prosthesisD5820 Interim partial denture (maxillary) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85.00D5821 Interim partial denture (mandibular) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85.00

Other removable prosthetic servicesD5850 Tissue conditioning, maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00D5851 Tissue conditioning, mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.00

D6200-D6999 IX. PROSTHODONTICS, FIXED – Procedures subject to 6 month waitingperiod(Each abutment and each pontic constitutes a unit in a fixed partial denture.)

Partial denture ponticsD6210 Pontic — cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171.00D6211 Pontic — cast predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138.00D6212 Pontic — cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168.00D6214 Pontic — titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171.00D6240 Pontic — porcelain fused to high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176.00D6241 Pontic — porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 155.00D6242 Pontic — porcelain fused to noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170.00D6250 Pontic — resin with high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176.00D6251 Pontic — resin with predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155.00D6252 Pontic — resin with noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170.00

Fixed partial denture retainers – inlays/onlaysD6545 Retainer — cast metal for resin bonded fixed prosthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.00D6602 Inlay — cast high noble metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.00D6603 Inlay — cast high noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D6604 Inlay — cast predominantly base metal, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.00D6605 Inlay — cast predominantly base metal, three or more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D6606 Inlay — cast noble metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.00D6607 Inlay — cast noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D6610 Onlay — cast high noble metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6611 Onlay — cast high noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6612 Onlay — cast predominantly base metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6613 Onlay — cast predominantly base metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6614 Onlay — cast noble metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6615 Onlay — cast noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6624 Inlay — titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D6634 Onlay — titanium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00

Fixed partial denture retainers — crownsD6720 Crown — resin with high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00 D6721 Crown — resin with predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161.00D6722 Crown — resin with noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.00 D6750 Crown — porcelain fused to high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00D6751 Crown — porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161.00 D6752 Crown — porcelain fused to noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.00D6780 Crown — 3/4 cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00D6781 Crown — 3/4 cast predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00 D6782 Crown — 3/4 cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00D6790 Crown — full cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180.00D6791 Crown — full cast predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.00D6792 Crown — full cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.00D6794 Crown — titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180.00

Other fixed partial denture servicesD6930 Recement fixed partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.00D6940 Stress breaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.00D6970 Cast post and core in addition to fixed partial denture retainer . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.00D6971 Cast post as part of fixed partial denture retainer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.00D6972 Prefabricated post and core in addition to fixed partial denture retainer . . . . . . . . . . . . . . . . . . . . 44.00D6973 Core buildup for retainer, including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.00D6980 Fixed partial denture repair, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00

D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY – Procedures subject to 6 month waiting periodExtractions (includes local anesthesia, suturing, if needed, and routine postoperative care)D7111 Extraction, coronal remnants — deciduous tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 20.00D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal). . . . . . . . . . . . . . . . 39.00

Surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative care)D7210 Surgical removal of erupted tooth requiring removal of bone and/or section of tooth . . . . . . . . . 74.00D7220 Removal of impacted tooth — soft tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.00D7230 Removal of impacted tooth — partially bony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117.00D7240 Removal of impacted tooth — completely bony, with unusual surgical complications . . . . . . . . . 134.00D7250 Surgical removal of residual tooth roots (cutting procedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78.00

Other surgical proceduresD7260 Oroantral fistula closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225.00D7261 Primary closure of a sinus perforation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225.00D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth . . . . . . . . . . 132.00D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98.00D7285 Biopsy of oral tissue — hard (bone, tooth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136.00D7286 Biopsy of oral tissue — soft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108.00

Alveoloplasty — surgical preparation of ridge for denturesD7310 Alveoloplasty in conjunction with extractions — per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . 59.00D7311 Alveoloplasty in conjunction with extractions — one to three teeth or tooth spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.00D7320 Alveoloplasty not in conjunction with extractions — per quadrant . . . . . . . . . . . . . . . . . . . . . . . . 96.00D7321 Alveoloplasty not in conjunction with extractions — one to three teeth or tooth spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58.00

VestibuloplastyD7340 Vestibuloplasty — ridge extension (secondary epithelialization) . . . . . . . . . . . . . . . . . . . . . . . . . . 82.00D7350 Vestibuloplasty — ridge extension (including soft tissue graft, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). . . . . . . . . 218.00

Surgical excision of soft tissue lesionsD7411 Excision of benign lesion greater than 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240.00D7465 Destruction of lesion(s) by physical or chemical method, by report . . . . . . . . . . . . . . . . . . . . . . . . 100.00

Surgical excision of intra-osseous lesionsD7440 Excision of malignant tumor — lesion diameter up to 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . 110.00D7441 Excision of malignant tumor — lesion diameter greater than 1.25 cm . . . . . . . . . . . . . . . . . . . . . 160.00D7450 Removal of benign odontogenic cyst or tumor — lesion diameter up to 1.25 cm . . . . . . . . . . . . . 131.00D7451 Removal of benign odontogenic cyst or tumor — lesion diameter greater than 1.25 cm . . . . . . . . . 273.00D7460 Removal of benign nonodontogenic cyst or tumor — lesion diameter up to 1.25 cm . . . . . . . . . . 128.00D7461 Removal of benign nonodontogenic cyst or tumor — lesion diameter greater than 1.25 cm . . . . . . . . 220.00

Excision of bone tissueD7471 Removal of lateral exostosis (maxilla or mandible) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 162.00D7472 Removal of torus palatinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162.00D7473 Removal of torus mandibularis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162.00D7485 Surgical reduction of osseous tuberosity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162.00D7490 Radical resection of maxilla or mandible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,000.00

Surgical incisionD7510 Incision and drainage of abscess — intraoral soft tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 .00D7520 Incision and drainage of abscess — extraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70.00D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue . . . . . . . . . . . . . . . 59.00D7540 Removal of reaction-producing foreign bodies, musculoskeletal system . . . . . . . . . . . . . . . . . . . . 60.00D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone . . . . . . . . . . . . . . . . . . . . . . . . . 85.00D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body. . . . . . . . . . . . . . . . . . . . . . . 237.00

Treatment of fractures — simpleD7610 Maxilla — open reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470.00D7620 Maxilla — closed reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 377.00D7630 Mandible — open reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929.00D7640 Mandible — closed reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 890.00D7650 Malar and/or zygomatic arch — open reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600.00D7660 Malar and/or zygomatic arch — closed reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200.00D7670 Alveolus — closed reduction, may include stabilization of teeth. . . . . . . . . . . . . . . . . . . . . . . . . . 190.00D7680 Facial bones — complicated reduction with fixation and multiple surgica approaches . . . . . . . . 1,000.00

Treatment of fractures — compoundD7710 Maxilla — open reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.00D7720 Maxilla — closed reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.00D7730 Mandible — open reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,000.00D7740 Mandible — closed reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 748.00D7750 Malar and/or zygomatic arch — open reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800.00D7760 Malar and/or zygomatic arch — closed reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200.00D7770 Alveolus — open reduction stabilization of teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300.00 D7780 Facial bones — complicated reduction with fixation and multiple surgical approaches . . . . . . . . 1,000.00

Reduction of dislocation and management of other temporomandibular joint dysfunctionsD7810 Open reduction of dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800.00D7820 Closed reduction of dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.00D7830 Manipulation under anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172.00

Repair of traumatic woundsD7910 Suture of recent small wounds up to 5 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200.00

Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure)D7911 Complicated suture — up to 5 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400.00D7912 Complicated suture — greater than 5 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600.00

Other repair proceduresD7960 Frenulectomy (not incidental to another procedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115.00D7970 Excision of hyperplastic tissue — per arch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.00D7971 Excision of pericoronal gingival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.00D7972 Surgical reduction of fibrous tuberosity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.00D7980 Sialolithotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233.00D7981 Excision of salivary gland, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,000.00D7982 Sialodochoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00D7983 Closure of salivary fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.00

D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICESUnclassified treatmentD9110 Palliative (emergency) treatment of dental pain — minor procedure. . . . . . . . . . . . . . . . . . . . . . . 41.00

AnesthesiaD9220 Deep sedation/general anesthesia — first 30 minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.00D9221 Deep sedation/general anesthesia — each additional 15 minutes . . . . . . . . . . . . . . . . . . . . . . . . 36.00

Professional visitsD9430 Office visit for observation (during regularly scheduled hours) — no other services performed . . . . . 24.00D9440 Office visit — after regularly scheduled hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49.00

DrugsD9610 Therapeutic drug injection, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.00

Miscellaneous servicesD9930 Treatment of complications (postsurgical) — unusual circumstances, by report . . . . . . . . . . . . . . 19.00D9951 Occlusal adjustment — limited . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.00

Note: This Appendix represents codes and nomenclature excerpted from the version of Current Dental Terminology (CDT) in effect at the date of this Contract or amendment was issued. CDT coding and nomenclature are the copyright of the American Dental Association, and have been accepted as the standard for data transmission purposes under federal Administrative Simplification regulations. For the purposes of this Appendix, Delta Dental’s administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the then current version of CDT whether or not a revised Appendix B is provided. Notes in italic type have been added by Delta Dental for clarification.

Code Description Allowance Code Description AllowancePaddison Dental Group #12190112501 Norwalk Blvd 562-929-0880 P/T 2 (SP, PE)Pioneer Dental Inc #01259014034 Pioneer Blvd 562-863-8779 P/T 1 (PE, SP)Rose Dental Implant Center #02929413041 Rosecrans Ave Ste 207 562-404-1614 P/T 1 (KO, SP) U

OCEANSIDEBright Now! Dental #0335834170 Oceanside Blvd Ste 183 760-936-0000 F/T 1 P/T 5 (SP) U

College Dental Group #007275467 College Blvd Ste 2 760-631-3060 F/T 2 P/T 1 (SP)Dentistry 2000 #0023213529 Cannon Rd Ste 2G 760-945-7000 F/T 1 (SP, PE)Emerald Dental #0295104645 Frazee Rd Ste A 760-722-0137 F/T 1 P/T 1 U

Quarry Creek Dental Group #0111443430 Marron Rd Ste 300 760-730-1303 P/T 1 U

Randall Segovia, DDS., Inc #0164723837 Plaza Dr Ste 805 760-630-6354 F/T 1FrSouth Oceanside Dental Group #0111532484 Vista Way Ste B 760-439-0334 P/T 2 (SP) U

ONTARIOBright Dental Care #0039692543 S Euclid Ave 909-933-5266 F/T 1 (SP, AR) U

Euclid Dental Center #0165852905 S Euclid Ave Ste D 909-391-4300 F/T 1 (PE, SP)Family Dentistry #000194628 W Holt Blvd Ste C 909-986-6424 F/T 1 (SP) U

HS Gill Archibald Ranch Dtl #0088523065 S Archibald Ave Ste B 909-923-3640 P/T 1 (SP, VI) U

Irene Justin, DDS #0265712413 S Grove Ave 909-947-9700 P/T 2 (SP, HI, AR)Jaswant Suthar, DDS #3672012242 S Mountain Ave 909-391-1549 F/T 1 (SP) U

Kyung Chung, DDS #357001941 W Mission Blvd Ste H 909-984-7883 F/T 1 (KO, SP)New Century Dental Care #0214441520 N Mountain Ave Ste 123 909-988-9690 F/T 1 P/T 1 (SP, CH, JA) U

Ontario Family Dentistry #022868528 N Fern Ave 909-460-9552 F/T 2 (SP, CH) U

Ontario Smiles #0244664190 E 4th St Ste C 909-532-8518 F/T 1 (SP)Ontario Village Dental #019519533 W Holt Blvd Ste B 909-988-1992 P/T 1 (SP)Prime Dental Office #0228691049 W Philadelphia St 909-391-2324 F/T 1 P/T 1 (HI, EI, SP)River Arch Dental Group #0146162920 S Archibald Ave Ste C 909-923-2273 P/T 1 (SP, VI) U

William Stanley, DDS #001601211 N Euclid Ave 909-983-9639 F/T 2 P/T 1 (SP)ORANGEAce Dental #0137672291 N Tustin St 714-282-2525 F/T 1 (SP, VI) U

Bright Dental Care #025940765 N Tustin St 714-771-7474 F/T 1Ca Dental Group of Orange #0086701502 E Collins Ave 714-288-8464 P/T 1 (SP, VI)Cecile N Licauco, DDS #0342828418 E Chapman Ave 714-984-2050 (SP, TA)Comfort Smile #1C53011920 E Katella Ave Ste J 714-997-4133 F/T 1 (SP, CH)

Newport Dental #0047151710 E Chapman Ave 714-538-2311 F/T 4 P/T 9 (CH, SP)OC Smile Factory #032185245 N Glassell St 714-532-5600 F/T 1 (SP)Orange Dental Group #033008235 S Tustin St 714-744-0044 P/T 1 (SP) U

Orange Dental Office #002804424 S Main St Ste H 714-639-1922 F/T 1 P/T 1 U

Orange Hill Dental #2824013138 E Chapman Ave 714-639-2703 F/T 1 (SP, PE) U

Preferred Dental Care #0043932022 W Chapman Ave 714-978-3333 F/T 1 P/T 2 (SP, CH, VI) U

Prime Dental Care #013980805 W La Veta Ave Ste 210 714-639-6666 P/T 1 (SP, AR, FR) U

Shiny Dental Practice #0117381916 N Tustin St 714-282-9966 F/T 1 (PE, SP) U

St Catherine Dental Center #001875235 E Katella Ave 714-633-3336 P/T 2 (SP, VI) U

Town & Country Dental #3678011111 Town & Country Rd # 33 714-285-0505 F/T 3 (CH, SP) U

Tustin Plaza Dental #2804011872 N Tustin St 714-637-8662 F/T 1 P/T 2 (JA, SP, VI)West Coast Dental #006975179 N Tustin St 714-288-1035 P/T 2 (SP, TA, HI) U

OXNARDAna Hernandez Carr, DDS #222901979 W 7th St 805-985-1159 F/T 1 (SP)Beach Cities Dental Group #0306761801 Solar Dr Ste 290 805-278-8887 F/T 1 U

Dental Care of Oxnard #1C36011350 W Gonzales Rd Fl 2 805-988-5888 P/T 1 (SP) U

Esthetic Smiles #3955011901 Solar Dr Ste 135 805-988-2250 F/T 1 (AR, FR, SP) U

Fremont Square Fmly Dentistry #002749712 N Ventura Rd 805-988-4540 F/T 1 (SP) U

Iraj Movahhedi, DDS #019926 4225 Saviers Rd Ste 9 805-982-8283 F/T 1 (SP)Island Plaza Dental Group #0028232500 Saviers Rd 805-486-4896 P/T 2 (SP) U

Jean Francisco Braza, DDS #0123481050 N Ventura Rd 805-981-8880 F/T 1 (SP, TA)Luz Cubillos, DDS #004719451 W Gonzales Rd Ste 160 805-988-3303 F/T 1 (FR, SP) U

Oxnard Dental Group #0165052379 N Oxford Blvd 805-278-9499 P/T 1Pacific Dental Group #0023252150 N Rose Ave 805-604-0449 P/T 1 (SP) U

Rose Dental Group #0181752731 S Rose Ave Ste 101 805-483-3658 P/T 2 (SP) U

PACOIMAKishore Shah, DDS #14840113279 Van Nuys Blvd 818-899-2505 F/T 1 P/T 1 (SP, TA)Pacoima Fmly Dental Center #0182589722 Laurel Canyon Blvd 818-897-1234 F/T 1 (SP, PE)Paradise Dental Group #03149410059 Lrl Cyn Blvd Ste A 818-896-0043 P/T 1 (SP) U

Urizar Dental Clinic #00209213215 Van Nuys Blvd 818-890-6442 P/T 1 (SP)Wilfrido Gedang, DMD #01357913564 Van Nuys Blvd 818-897-5771 F/T 1

PALM DESERTDesert Crossing Dental Group #2C370172333 Highway 111 Ste B 760-674-9666 P/T 1 (SP) U

Desert Dental Assoc #03310072210 Highway 111 Ste E-1 760-773-2111 P/T 1 U

Desert Gateway Dental Group #02288834460 Monterey Ave Ste 100 760-321-1259 F/T 1 P/T 1 (SP, AR) U

Palm Desert Dental Center #02459073733 Fred Waring Dr Ste 207 760-773-0052 F/T 1 P/T 1 (PE, SP) U

Parc Center Dental #02626077564 Cntry Club Dr Ste 350 760-772-7082 F/T 1 P/T 1Sunlife Dental Group #03185373211 Fred Waring Dr Ste 201 760-568-3368 F/T 1 (SP) U

PALM SPRINGSDesert Dental Group #1998011111 Tahquitz Cyn Way 210 760-327-1125 F/T 1 P/T 2 (SP)Palm Canyon Dental Office #029953180 E Palm Canyon Dr 760-322-1002 F/T 1PALMDALEAndre Kanarki, DDS #0009971543 E Palmdale Blvd Ste B 661-274-1866 F/T 1 (AM, FR, SP, TA)Bright Now Dental #02096839345 10th St W Ste B 661-274-8065 F/T 2 P/T 15 (SP)Gateway Dental Group #02673238209 47th St E Ste E 661-236-0046 F/T 1Hi-Desert Dental Center #0017322205 E Palmdale Blvd 661-273-1333 F/T 1 P/T 1 (RU, SP, PE) U

Oasis Dental Care #02587040008 10th St W Ste F 661-947-2727 F/T 1 (PE, SP)Premier Dental Care #1C08013005 E Palmdale Blvd Ste 22 661-273-5221 P/T 1 (AM, AR, SP) U

Sierra Commons Dental Grp #017650755 W Rancho Vista Blvd 661-265-7800 F/T 1 P/T 1 (SP) U

Smilecare-Palmdale #00150738745 Tierra Sub Ave Ste 150 661-272-9091 F/T 2 P/T 4 (SP) U

Thelma Buado, DDS #0210263025 E Avenue S Ste A14 661-265-7694 F/T 1 (SP, TA) U

PALOS VERDES PENINSULAPeninsula Dental Arts #3C3801550 Deep Valley Dr Ste 347 310-377-9575 P/T 2 (SP, PE)PANORAMA CITYDan Rosen/Sr Nourian DDS #3418018424 Van Nuys Blvd 818-893-4222 P/T 2 (SP, PE, HE) U

Dental Plus California #01344514415 Chase St 818-830-9050 P/T 3 (SP) U

Dental Wonderland #0168698761 Van Nuys Blvd 818-891-1600 F/T 1 P/T 2 (SP, AM, AR, FR) U

Dentalville #0219197864 Van Nuys Blvd 818-989-2400 F/T 3 P/T 1 (AM, RU, SP, TA) U

Erlinda Rosenthal, DMD #01722913760 Roscoe Blvd 818-893-9222 F/T 1 (SP, TA) U

Gary Karsh, DDS #3572018614 Van Nuys Blvd 818-895-1321 P/T 1 (RU, SP) U

Gentle Dental Center #3C480114526 Roscoe Blvd 818-893-7858 P/T 1 (RU, SP)Koo DDS., Inc #0130598215 Van Nuys Blvd Ste 220 818-782-8261 P/T 2 (CH, KO, SP)Latin Dental Group #0309548111 Van Nuys Blvd Ste 107 818-994-6080 F/T 1 (SP) U

Shimon Rabbani, DMD #01235014554 Nordhoff St 818-891-2345 F/T 1 (SP)Van Nuys Panorama Dental Ctr #0028038227 Van Nuys Blvd 818-989-3074 F/T 1 (AR, SP) U

PARAMOUNTDr Chebbi Dental Office #01864916260 Paramount Blvd Ste G 562-633-5070 F/T 1 P/T 1 (AR, FR, SP)Paramount Family Dental Ctr #3707018131 Rosecrans Ave Ste 101 562-634-2984 F/T 1 (SP, CH) U

West Coast Dental #35590114525 Lakewood Blvd Ste A 562-272-0000 P/T 2 (SP)PASADENAAlen Baktamian, DMD #3C2601301 S Fair Oaks Ave Ste 208 626-431-2654 P/T 1 (AM, PE, SP) U

Arakelyan Dental #001746720 N Lake Ave Ste 7 626-808-9797 P/T 1 (AM, RU) U

David Wyndhamsmith, DDS #3166011092 E Green St 626-795-9328 P/T 2 (KO, SP) U

Dental Plus/Leon Roisman DMD #038601310 S Lake Ave Lowr Level 626-795-6855 F/T 4 (SP) U

Fair Oaks Family Dental #028398929 N Orange Grove Blvd 626-449-3700 F/T 3 P/T 2Gentle Care Health Spa #022435247 N Lake Ave 626-405-2922 P/T 1 (AM, AR, SP) U

Green Street Dental #3593011175 E Green St 626-578-1687 F/T 1 U

Hastings Ranch Dental Group #017210255 N Rosemead Blvd 626-351-0195 P/T 1 U

Ibrahim Rabadi, DDS #0217782281 E Washington Blvd 626-794-2606 F/T 1 (AM, AR, TR, RU) U

Lakeview Dental #019231709 N Lake Ave 626-797-8900 P/T 1 U

Newport Dental Pasadena #01290881 N Lake Ave 626-440-0240 F/T 2 P/T 15 (SP, AM, PE, VI)Pasadena Dental Associates #2724011302 N Altadena Dr 626-797-6778 F/T 2 (AM, CA, SP)Pasadena Dental Center #004502766 N Lake Ave 626-808-1717 P/T 1Pasadena Family Dental Center #001902950 E Colorado Blvd Ste 201 626-431-2930 P/T 1 (SP) U

Rene & Tina Ghotanian, DDS #016419212 S El Molino Ave 626-792-7900 P/T 2Rose City Dental Arts #0188821855 E Colorado Blvd 626-440-0801 P/T 1 U

Shaun Malek, DDS #148701465 N Lake Ave 626-405-1445 F/T 1 (SP) U

Sinai Dental Practice #031178668 N Los Robles Ave 626-405-9090 F/T 1 U

Superb Dental Care #031651109 W California Blvd 626-844-7778 P/T 1 (SP, TA) U

Washington Dental Group #1C82012554 E Washington Blvd 626-296-0056 F/T 1 P/T 1 (SP) U

PERRISCrossing Dental Group #0228853150 Case Rd Bldg C 951-345-4386 P/T 2 (SP) U

Gentle Dental Perris #0329812560 N Perris Blvd Ste F1 951-657-6466 P/T 3Perris Family Dental Care #013535330 E 4th St 951-940-5855 P/T 1 (SP)PICO RIVERAAshokkumar Mehta, DDS #3206019514 Whittier Blvd 562-942-2345 P/T 1 (SP, FR, VI) U

Bright Smile Dental #0250678819 Whittier Blvd Ste 102 562-699-1000 F/T 1Cord Family Dental Care #0217008716 Cord Ave 562-949-2526 F/T 2 (SP, PE) U

Danny Muditajaya, DDS #3675019123 Slauson Ave 562-949-0177 F/T 4 (SP, TA) U

Dental Masters #0127458982 Washington Blvd 562-222-1551 F/T 1 P/T 1 (SP) U

Family Dentistry #0000134400 Rosemead Blvd Ste 2 562-695-5251 F/T 1 (HI, SP) U

Pico Rivera Family Dentistry #0292819401 Slauson Ave 562-949-9500 F/T 1 P/T 1Prime Care Dental #0238578803 Whittier Blvd Ste 200 562-463-6163 P/T 2 (KO, SP)Rivera Family Dental #1439019050 Whittier Blvd 562-942-8900 F/T 1 (AM, SP) U

PLACENTIACoastal Dental Care #0078791858 N Placentia Ave 714-577-9070 P/T 2 (SP, VI) U

Imperial Rose Fmly Dentistry #0292961061 E Imperial Hwy 714-577-7575 F/T 1 (KO, SP) U

Naomi and Anthony Wong DDS #004485415 W Chapman Ave 714-223-2021 P/T 2 (CH, SP)Placentia Family Dentistry #0160131525 N Placentia Ave Ste H 714-528-0089 F/T 1 (CH, SP, VI)Rose Linda Dental #0016741203 E Yorba Linda Blvd 714-528-2833 F/T 1 (GE, SP, PE) U

PLAYA DEL REYDel Dental Group #0129418035 W Manchester Ave Ste B 310-822-8118 P/T 1 (SP, PE) U

POMONABella Manchandia, DDS #001718551 E Holt Ave 909-622-8600 F/T 1 (HI)Donald Hodson, DDS #3480011956 Indian Hill Blvd 909-621-5848 F/T 1 (SP, PE)Family Dental Clinic #0054932280 S Garey Ave 909-364-0633 F/T 2 P/T 1 (SP)Gentle Dental Pomona #198201175 W La Verne Ave Ste A 909-593-5515 F/T 2 P/T 1 U

Grove Family Dental #0174763167 N Garey Ave 909-596-7700 P/T 3 (SP, HI, PE)Harpreet Gill, DDS #308201722 E Arrow Hwy 909-621-9177 P/T 1 (SP, TA) U

Kent Hung, DMD #011786520 E Foothill Blvd Ste B 909-624-1781 P/T 1 (CH, SP)Larissa Gushansky, DDS #017478887 E 2Nd St Ste D 909-865-8595 F/T 1 (SP, RU, CH)Pearl Dental Care #0111432407 Valley Blvd Ste C1 909-839-1004 P/T 1 (SP, HI) U

Pomona Dental Group #357101850 Indian Hill Blvd 909-626-3541 F/T 1 (KO, SP)Pomona Family Dental #032351956 N Garey Ave 909-629-9741 F/T 1Sahara Dental #0025092005 W Holt Ave 909-623-9590 F/T 1 P/T 1 (AR, SP) U

Zahra Dental Group #029158180 E Mission Blvd 909-623-5278 F/T 2 P/T 1 (PE, SP)POWAYA Poway Dental Group #00186713422 Pomerado Rd Ste 202 858-679-4949 P/T 1 U

Healthy Habit Dental #02423012620 Monte Vista Rd Ste D 858-485-8800 F/T 1 (SP) U

Pomerado Family Dental Grp #00962915706 Pomerado Rd Ste 201 858-674-5252 F/T 1 (SP)Poway Family Dental Group #00727313616 Poway Rd Ste 100 858-391-9300 P/T 2 (SP) U


6 31

MAYWOODMaywood Dental Care #0264636059 Atlantic Blvd 323-560-3131 F/T 1 (KO, SP)New Millennium Dental Group #0168116021 Atlantic Blvd 323-560-6096 P/T 1 (RU, SP) U

Southeast Dental Group #1596014332 Slauson Ave 323-588-2141 F/T 2 P/T 3 (GE, SP, TA, CH) U

Summer Dental Group #0319524201 Slauson Ave 323-560-4658 F/T 1 P/T 1 (SP) U

Summer Verano Dental Group #0264614201 Slauson Ave 323-560-4658 P/T 1 (SP, TA)MENIFEEMenifee Smiles Dentistry #02685330406 Haun Rd Ste 740 951-679-4624 F/T 1 P/T 2 (SP) U

Menifee Valley Dental Group #18320126910 Newport Rd Ste B 951-672-9457 P/T 1 (SP, PE)Quynh Tran Nguyen Dent Corp #03166327174 Newport Rd Ste 1 951-723-8801 P/T 1 (VI) U

MEXICALIDenticenter #351701460-1 Avenida Modero 760-235-4162 F/T 1 (SP)MIRA LOMAGateway Dental of Eastvale #01117412571 Limonite Ave Ste 230 951-360-3444 F/T 1 P/T 1 (SP) U

Limonite Dental Group #02669612363 Limonite Ave Ste 960 951-371-7711 F/T 1 (CH, SP, VI)Mira Loma Dental Centers #00254611058 Limonite Ave 951-737-6005 F/T 1 (HI, SP) U

Mira Loma Smiles #0226116445 Pats Ranch Rd Ste G 951-808-5881 P/T 2 (SP) U

MISSION HILLSArjomand Madadshahi, DDS #01573715501 Sanfernando Mission104 818-365-8600 F/T 1 (SP, PE) U

Bright Dental Group #02149115534 Devonshire St Unit 108 818-830-4100 P/T 1 (PE) U

Devonshire Dental #02139015300 Devonshire St Ste 6 818-894-6411 F/T 1 P/T 1Parviz Kohanoff, DDS #35550111550 Ind Hills Rd Ste 281 818-361-8777 F/T 1 (PE, SP) U

MISSION VIEJOAmazing Smiles Dental Care #03350526800 Crown Valley Pkwy 385 949-388-3878 F/T 1 (PE, SP, TA) U

Appealing Dentistry Msn Viejo #27100126302 La Paz Rd Ste 211 949-766-7687 F/T 1 (HE, PE, PL, RU, SP) U

Avalon Dentistry #02521127725 Snta Mrgarita Pky #270 949-951-0951 F/T 2 (PE, SP, TA, VI) U

California Dental Care #01561128201 Marguerite Pkwy Ste 10 949-347-0302 P/T 1 (JA, PE, SP) U

Gateway Dental Group #02330024000 Alicia Prkwy #34 949-707-7000 F/T 1 (PE) U

Gentle Dental Mission Viejo #00887725523 Marguerite Pkwy Ste C 949-768-1800 F/T 3 P/T 2 (AR, GE, HI, PE, SP) U

James Vartanian, DDS., Inc #02289126302 La Paz Rd Ste 203 949-586-5669 F/T 1 U

Marguerite Dental Care #01994827871 Medical Ctr Rd #165 949-364-2529 F/T 1 (FR, PE, SP) U

Mission Dental Group #01427126032 Marguerite Pkwy # A-1 949-582-8400 P/T 2 (SP) U

Mission Viejo Dental #02140823482 Alicia Pkwy 949-581-0090 F/T 5 P/T 7 (IN, PE, SP, VI) U

Mission Viejo Dental Assoc #00186625522 Marguerite Pkwy # 100 949-586-6200 F/T 1 P/T 1 (CH, SP) U

New Smile Dental #02168724481 Alicia Pkwy Ste B3 949-586-9800 F/T 1 (PE, SP) U

Raed Fawaz, DDS #01715226902 Oso Pkwy Ste 190 949-582-9206 F/T 1 (SP)Saddle Back Dental Ctr #02331323166 Los Alisos Blvd # 230 949-457-0223 F/T 1 (AR, PE, TA) U

Trabuco Dental #03310227725 Sta Margarita Pkwy 261 949-597-2444 P/T 1 (AR, SP)MONROVIAFoothill Dental Center #155501154-A W Foothill Blvd 626-305-5722 P/T 1 (SP, VI) U

MONTCLAIRAmiel Patel, DDS #3C25014921 Moreno St 909-625-3865 F/T 1Central Family Dentistry #1795019197 Central Ave Ste C 909-398-1107 F/T 1 (CH, SP, TA)Johnson Family Dentistry #1991019645 Monte Vista Ave Ste 305 909-621-6002 F/T 2 (SP)MONTEBELLODaniel Farkas, DDS #2109013301 W Beverly Blvd 323-722-6766 F/T 4 P/T 1 (SP) U

Dental Ville #013595833 W Whittier Blvd 323-266-1000 P/T 2 (SP)Dr Davids Family Dentistry #2393012100 W Beverly Blvd 323-724-9536 F/T 1 (SP) U

Dr Gregory Robins Fmly Dstry #019967604 N Montebello Blvd # B 323-721-0799 F/T 1 P/T 1 (CH, GE, KO, SP) U

Greenwood Dental #1569011214 1/2 S Greenwood Ave 323-728-3272 F/T 1 (FR, SP) U

Margaret Wu, DDS #0224181717 W Beverly Blvd 323-724-9326 F/T 1Montebello Dental Associates #013239711 W Whittier Blvd 323-278-0170 P/T 1 (PE, SP, AM) U

Montebello Dental Center #0251882332 W Whittier Blvd 323-838-8055 F/T 1National Dental #013236249 E Beverly Blvd Ste A 323-726-7500 F/T 1 P/T 1 (SP, VI) U

S Ghazarian, DDS #363901433 N Montebello Blvd 323-722-2922 F/T 1 (AM, PE, SP) U

Smilecare-Montebello #0039521451 N Montebello Blvd 323-724-9955 F/T 2 P/T 5 (SP) U

Tigran Hovannisyan, DDS #0211072059 W Whittier Blvd 323-727-9898 F/T 1 (AM, RU, SP) U

Vista Sol Dental #0140171000 W Whittier Blvd 323-346-0555 P/T 1 (FR, PE, SP) U

MONTEREY PARKA Gary Kelleyan DDS #021887616 N Garfield Ave Ste 404 626-280-4122 F/T 1 (SP)Central Dental #0037082111 S Atlantic Blvd 323-261-9999 P/T 1 U

Golden Dragon Family Dntry #026502871 S Atlantic Blvd 626-284-4200 F/T 2 (SP, CH)Isaac Chen, DDS #2396012071 S Atlantic Blvd Ste F G 323-260-7878 F/T 1 P/T 2 (CH, KO, SP) U

Pacific Dental Group #1964012016 S Atlantic Blvd 323-725-6797 P/T 1 (AM, IT, PE, SP) U

MOORPARKMoorpark Dental Group #020308718 W Los Angeles Ave # 3 805-529-1743 P/T 1 (SP) U

Moorpark Smiles Dental #028898144 W L.A. Ave Ste 114 805-553-1980 P/T 1 (SP) U

MORENO VALLEYBright Now! Dental #01050912420 Day St Ste B4 951-656-6538 F/T 2 P/T 20 (CH, SP, TA, VI) U

California Dental Office #00913012800 Heacock St Ste A1 951-247-2688 F/T 2 P/T 2 (CH, SP, VI)Community Dental of Dr Chi #00353111875 Pigeon Pass Rd Ste B9 951-488-8688 P/T 1 (CH, SP)Dtl Assoc/Moreno Valley Mall #39630122500 Town Cir Ste 2074 951-697-6800 F/T 1 (SP)Family Dentistry #03100323962 Alessandro Blvd Ste R 951-697-8888 F/T 1 U

Harry Karna, DDS #03120012264 Perris Blvd 951-485-2800 F/T 1 (HI, SP, TA) U

James Dickey, DDS #34620124266 Postal Ave Ste 100 951-242-2600 F/T 1Moreno Dental Care #02962423750 Alessandro Blvd # O102 951-656-0088 F/T 1 P/T 1 (KO, SP, TA) U

Robert Silvola, DDS #27330112810 Heacock St Ste B103 951-242-3441 F/T 1 (SP)Smilecare-Moreno Valley #00310512125 Day St Bldg N Ste 211 951-222-2000 F/T 1 P/T 3 (SP)St Patrick Dental Clinic #01583724655 Sunnymead Blvd 951-242-6088 P/T 2 (TA) U

Stoneridge Dental Group #02246927110 Eucalyptus Ave Ste A 951-616-1759 P/T 1 (SP) U

Towngate Family Dental #03312712625 Frederick St Ste F4 951-697-7750 F/T 1 U

MURRIETACal Oaks Dental Excellence #03089540414 Calif Oaks Rd Rd#A 951-304-7472 P/T 1 (PE, SP) U

Copper Canyon Smiles #01760523771 Washington Ave # H1-02 951-691-5096 P/T 1 (SP) U

Friendly Dental Center #02613739252 Winchester Rd Ste 117 951-894-7769 P/T 1 (VI, SP, PE) U

Madison Springs Dental #2C590125285 Madison Ave Ste 107 951-698-3585 F/T 2 P/T 1 (SP)Margarita Dental Group #01741039400 Murrieta Ht Sprs #123B 951-461-7470 P/T 1 (SP, CH, VI)Murrieta Dental Excellence #02836840165 Mur Ht Spgs Rd Ste M 951-696-2515 P/T 1 U

Murrieta Dental Group #0C220140770 California Oaks Rd 951-677-3078 P/T 2 (SP)Murrieta Dental Group #00316525395 Madison Ave Ste 103 951-696-5660 P/T 3 (SP, VI)Murrieta Family Dental Group #3C860140643 California Oaks Rd 951-677-7779 P/T 2 (SP)Plaza Dental Group #01777940484 Mur Ht Spgs Rd Spc Gs 951-461-4306 F/T 1 P/T 1 (SP) U

Watanabe & Espeleta Prof Dtl #01312139209 Winchester Rd 951-304-1348 F/T 1 P/T 1 (SP) U

NATIONAL CITYArtemio F Palaganas, DDS #0121651341 E 8th St Ste D 619-474-8441 F/T 1 (SP, TA)Richard Cervantes, DDS #3551012016 Highland Ave 619-477-3770 F/T 1 (SP, TA)South Coast Dental #012746400 Mile Of Cars Way # 400 619-477-1970 F/T 1 (SP)Thomas Toma, DMD #1812013460 Highland Ave Ste D 619-420-1100 F/T 2 (SP, TA)Town And Country Dental #0C23011536 Sweetwater Rd Ste E 619-477-4945 P/T 1 (SP, PE, GE)

NEWBURY PARKQuynh Tran Nguyen, DMD #0155931000 Newbury Rd Ste 138 805-498-8856 P/T 1 (VI) U

Steven Destler, DDS #171201587 N Ventu Park Rd Ste C 805-499-1253 F/T 1 P/T 1 (SP) U

NEWHALLCanyon Country Dental Group #00860526877 Sierra Hwy 661-251-2002 F/T 2 (SP, VI) U

Gabriel Henao, DDS #03113325044 Peachland Ave Ste 100 661-287-4352 F/T 1 (SP) U

Jerrold Singer, DDS #03235025061 Peachland Ave 661-255-7530 P/T 2Lyons Dental Care #00853624036 Lyons Ave 661-255-1015 P/T 2 (AM, PE, SP) U

Lyons Dental Place #02758023238 Lyons Ave 661-259-0600 F/T 1 P/T 1 (TA) U

Mitra Simanian, DDS., Inc #01482923206 Lyons Ave Ste 203 661-255-7338 P/T 1 (AM, PE, RU, SP) U

NEWPORT BEACHAmit Shah, DDS #013066355 Placentia Ave Ste 205 949-646-0818 F/T 1 (HI)Coastal Image Dental #0165443991 Macarthur Blvd Ste 228 949-863-0988 F/T 2 (CH, SP) U

Image Dental #0295961310 Bison Ave 949-760-0363 F/T 1 (VI) U

Joseph Di Caprio, DDS #32780120072 Sw Birch St Ste 150 949-752-2012 F/T 1 (SP)Newport Beach Dental #1258011501 Superior Ave Ste 100 949-650-6772 F/T 3 U

Newport Smiles #0216913333 W Coast Hwy Ste 303 949-642-1033 F/T 2 (PE, SP) U

Newport Smiles #0224143333 W Coast Hwy Ste 303 949-642-1033 F/T 1 (PE) U

Omid Haronian, DDS #0299511901 Westcliff Dr Ste 6 949-646-2481 F/T 1 (SP, PE)NIPOMONipomo Dental Arts #028317255 N Wilson Ave Ste D 805-929-3219 F/T 1NORCOHamner Dental Group #015152140 Hidden Valley Pkwy 951-898-8673 P/T 2 (HI, SP) U

Hidden Valley Dentistry #0264031161 Hidden Valley Pkwy #106 951-582-0200 F/T 1 (SP, PE)Norco Dental Practice #0069841260 Hamner Ave Ste C D 951-279-5200 F/T 2 P/T 2Norco Family Dental #1422012031 River Rd 951-372-9094 P/T 1 (PE, SP) U

NORTH HILLSDental Solutions #0075639146 Sepulveda Blvd Ste A 818-830-7000 P/T 1 (SP, TA) U

West Coast Dtl Grp N Hills #02212315350 Nordhoff St Ste A 818-672-8228 F/T 1 P/T 1 (SP, PE)NORTH HOLLYWOODAshok Gandhi, DDS #0133165942 Lankershim Blvd 818-985-7479 F/T 1 (HI, SP, TA) U

Daniel Boudaie Family Dentist #00279710941 Victory Blvd 818-509-1967 F/T 1 (SP, TA, AM, PE) U

Dental Plus California #0196416512 Laurel Canyon Blvd 818-623-9000 P/T 4 (SP) U

Family Dentistry #00166711436 Vanowen St 818-503-9697 F/T 1 P/T 1 (RU, SP)Hamlin Dental Group #00354612509 Oxnard St Ste 201 818-285-5757 P/T 2 (AM, SP)

Hersel Hanasab, DDS #01565412926 Sherman Way 818-765-4422 F/T 1 P/T 1 (PE, SP) U

Julian Gershfeld, DDS #3498015160 Vineland Ave Ste 105 818-761-8899 P/T 1 U

Magnolia Family Dentistry #02206311300 Magnolia Blvd Unit 5 818-980-7222 F/T 1 P/T 1 (RU, SP) U

Media District Dentistry #01888510732 Riverside Dr 818-760-9494 F/T 3 P/T 1 (PE, SP) U

Noho Dental Group #03265211126 Chandler Blvd 818-432-8300 P/T 2 (PE, RU, SP) U

North Hollywood Dental Grp #02112912125 Vanowen St Ste 2 818-764-4679 P/T 1 (AM, PE, SP, TR)Pacific Dental Group #0028406801 Lankershim Blvd Ste 101 818-764-0718 P/T 1 (RU, SP) U

Premier Dental Clinic #0199864648 Lankershim Blvd 818-505-0520 P/T 1 U

Santo Tomas Dental Group #02956012115 Saticoy St 818-759-1001 F/T 3 P/T 1 (SP, PE) U

Spectrum Dental Care #02176813112 Sherman Way 818-982-6162 F/T 1 P/T 1 (RU, SP) U

Star Smile Dental Grp #02385811404 Victory Blvd 818-508-7000 F/T 1 (SP, TA) U

Unique Smile Dental #0267684789 Vineland Ave Ste 202 818-761-4545 F/T 1 (AM, PE)NORTHRIDGEAt Ease Dentistry #02956711155 Tampa Ave 818-363-3382 F/T 1 (AM, RU, SP) U

Babak Kohanoff, DDS #37880118250 Roscoe Blvd Ste 225 818-349-9151 F/T 1 (SP, PE)Bharati Desai, DDS #3659018954 Reseda Blvd Ste 100 818-701-3010 F/T 1 (SP, HI)Carmen Magpantay, DDS #02717810321 Zelzah Ave 818-366-4118 F/T 1 U

Hamlin Dental Group #1764018540 Reseda Blvd Ste 101 818-701-6667 P/T 3 (SP, PE, TA, RO)Homa Shahriari DDS, Inc #0027538632 Balboa Blvd 818-894-6161 F/T 1 (SP, PE) U

Lawrance Levine, DDS #0264018363 Reseda Blvd Ste 202 818-885-0536 F/T 1 U

Northridge Dental Office #00824618519 Devonshire St 818-831-9990 F/T 1 P/T 2 (AM, SP) U

Northridge Family Dtl Center #0192609514 Reseda Blvd Ste 6 818-775-1300 F/T 1 (FR, SP)Richard Rothstein, DDS #1061019145 Reseda Blvd 818-886-9920 F/T 1 P/T 1 (KO, SP, CH)Shanram Nouri Dental Corp #0180179068 Tampa Ave 818-885-5200 F/T 1 (PE, SP) U

Smilecare-Northridge #00396517017 Devonshire St 818-360-2216 F/T 1 P/T 7 (SP) U

NORWALKChan Lee, DDS #36400111780 Firestone Blvd 562-868-9897 F/T 1 (CH, SP, TA) U

Newport Dental #01314011481 Rosecrans Ave 562-863-3457 F/T 4 P/T 8 (SP) U

Norwalk Dental! #01559112052 Imperial Hwy Ste 101 562-863-4775 F/T 2 P/T 7Norwalk Family Dental #00320412319 Imperial Hwy 562-868-7955 F/T 1 (SP, HI) U

Norwalk Family Dentistry #00272015617 Studebaker Rd Ste 5 562-484-3936 F/T 1 (SP, TA) U


n How to enroll in KPIC’s Dental Insurance Plan

1) Complete the enrollment form on page 7. If you are already a Kaiser Permanente member, please include a copy of your Kaiser Permanente ID card. If you are not yet a Kaiser Permanente member, please include a copy of your Medical Enrollment Form (Form SF 2809). You must be a Federal member of Kaiser Permanente to enroll.

2) Sign the form to authorize automatic payment from your checking, savings or credit union account. Be sure to enclose a voided blank check or deposit form from this account. Call your bank to obtain the automatic deposit routing number and write the number on the payment authorization form.

3) Return the first month’s payment and enrollment materials by December 21, 2010, to:

KPIC Federal Employee Group Dental Insurance PlanWolfpack Insurance Services, Inc.P.O. Box 720Belmont, CA 94002-0720

4) If your payment and enrollment materials are received by KPIC’s Administrator by December 21, 2010, your effective date of coverage (including your eligible dependents) will be January 1, 2011.

n Monthly Rates for Calendar Year 2011:

One person ...................................................................... $29.03 Two persons..................................................................... $51.44 Three or more persons .................................................... $77.32

n Payment of Monthly Charges

The dental coverage described in this brochure will not become effective until KPIC or its Administrator receives the initial premium from the eligible Federal Employee. The due date for subsequent premiums is the 10th day of each month. The Insured agrees to pay subsequent premiums no later than 31 days following the premium due date, unless the Insured has given notice requesting termination of dental coverage under the Certificate in accordance with the Termination section of the Certificate. The Insured will be responsible for the payment of the pro rata premium for the time dental coverage under the Certificate was in force during the 31-day grace period.

n Billing

To ensure timely processing of your benefits and claim payments, it is necessary that premiums be paid during the month prior to the coverage month. There are two payment options.

You may choose to have your monthly premiums deducted from your checking, savings or credit union account on the 10th of each month prior to the coverage month (e.g., April dues will be deducted on March 10). Please complete the Automatic Payment Authorization form on page 8 of this brochure.

If you do not have a checking, savings or credit union account, you may submit payments via a personal check, money order, etc. When completing the enrollment form, write DIRECT PAY across the top of page 8, “Automatic Payment Authorization.” You will be sent monthly invoices to submit with your premium payments. Premiums must be paid by the 10th of each month prior to the coverage month.

30 7

EN

RO

LL

ME

NT

FO

RM

Your full name Social security number

Kaiser Permanente Medical Record number

Mailing address

City State ZIP

Male Female Date of birth / / Phone number ( ) —

Please list eligible dependents to be covered in addition to yourself:

Spouse Male Female Date of birth / /

Child Male Female Date of birth / /





Enrollment — Coverage not elected below will be assumed refused if not specifically refused.

Yes, I would like to enroll in the Kaiser Permanente Insurance Company (KPIC) Group Dental Plan for Federal Employees. I understand that enrollment is voluntary. By electing to enroll, I agree to participate in the KPIC Trust (and/or any successor Trust), which holds the KPIC Group Dental Policy. I understand that to be eligible for the Plan, I must be enrolled along with any of my dependents to be covered, in Kaiser Permanente’s Traditional HMO Plan for Federal Enrollees. I further understand that my continued eligibility, and that of my covered dependents, is contingent on our continued enrollment in Kaiser Permanente’s Traditional HMO Plan for Federal Enrollees. I also understand that some covered dental services are subject to waiting periods. I certify that to the best of my knowledge and belief, any information disclosed on this enrollment form, is accurate and that my answers are correct, true and complete.

No, I do not wish to participate. I understand that I will not be entitled to any benefits under the KPIC Group Dental Plan and will not be able to enroll until the next annual renewal period. (Coverage not elected will be assumed refused, even if not specifically refused.)

Signature of enrollee _________________________________________________________________________________ Date __________________________

KPIC — Enroll — 9793 (rev. 9/2008)

GROUP DENTAL ENROLLMENT FORM

Enrollment Information — Failure to accurately complete the questions on the enrollment form may delay the effective date of your coverage under the KPIC Dental Insurance Plan.

Instructions: Please complete this Group Dental Enrollment Form and return a signed copy with your first month’s payment by December 21, 2010 to:Wolfpack Insurance Services Inc.

P.O. Box 720Belmont, CA 94002-0720

KAISER PERMANENTE INSURANCE COMPANYOakland, California

or

Aram Arakelyan, DDS #0183732426 W 8th St Ste 209 213-381-3900 P/T 1 (RU, AM, SP)Arturo V Hernandez, DDS #0263603120 W 6th St 213-351-7661 F/T 1 (SP, TA)Barry Kashfian, DMD #1256012080 Century Park E Ste 1406 310-553-1578 P/T 1 (SP, TA)Benji Behroozan, DDS #3655015255 W Sunset Blvd 323-463-7252 F/T 1 P/T 1 (PE, SP)Beverly Drive Dental Group #0127951125 S Beverly Dr Ste 750B 310-277-7645 P/T 1 (PE, SP) U

Beverly Hills Family Dental #0095381125 S Beverly Dr Ste 400 310-286-7447 F/T 1 (PE, SP) U

Boyle Heights Family Dntstry #0214812110 E Cesar E Chavez Ave 323-268-8308 F/T 1 (SP, KO)Brentwood Dental Group #00250711980 San Vte Blvd Ste 660 310-979-8345 P/T 1 (PE, SP, TA) U

Bright Now! Dental #0156474251 Crenshaw Blvd 323-295-5577 F/T 6 P/T 8 (SP)Brighter Dental #0018146221 Wilshire Blvd Ste 507 323-939-7899 P/T 1 (PE, SP, TA)Brite Dental #0291773530 Wilshire Blvd Ste 150 213-487-7771 P/T 2 (KO, SP) U

Byung Chul Kim, DDS #270601765 N Virgil Ave 323-665-5887 F/T 1 (KO, SP)California Dental Care #15210111628 Sta Mon Blvd Ste 101 310-207-1060 P/T 1 (SP) U

Calm Dental #031387525 S Olive St 213-624-3333 P/T 1 (PE, SP) U

Centro Medico/Dental Familiar #000635514 E Washington Blvd 213-749-3934 P/T 2 (RU, SP) U

Chantiste Beal, DDS #0303735010 S La Brea Ave 562-381-5626 F/T 1Cheryl Bingham, DDS #34900111905 S Central Ave Ste 203 323-564-7504 F/T 1 (SP)Chinatown Service Center #018954767 N Hill St Ste 200 213-808-1790 F/T 1 (CA, CH, SP, VI)Cohen Dental #0148609188 W Pico Blvd 310-276-9966 P/T 1 (PE, SP) U

Commerce Dental #0129475542 Whittier Blvd 323-722-8700 F/T 1 P/T 1 (RU, SP) U

Continental Dental Group #173201600 W Manchester Ave Ste 2 323-750-1582 P/T 1 (SP) U

Crown Dental Group #0103196907-A La Tijera Blvd 310-645-0336 P/T 1 (KO, SP) U

Crystal Dental #0280122206 S Figueroa St 213-748-8448 F/T 1 P/T 1 (CH, PE, SP) U

Culver Del Rey Dental Office #21190112202 W Washington Blvd 310-915-9797 F/T 3 P/T 1 (SP) U

Cypress Dental Clinic #0028652135 Cypress Ave 323-223-0731 F/T 1 (SP) U

Dan Benyamini, DDS #0006371826 W 7th St 213-484-6660 F/T 1 (PE, SP) U

David Daneshrad, DDS #12020111850 Wilshire Blvd Ste 101 310-477-8766 F/T 1 (SP, TA) U

Davis Famili DDS, Magd Inc #01994611500 W Olypmic Blv #508 310-477-7744 P/T 1 (SP, PE, FR) U

Dental Central Group #0109343009 S Vermont Ave 323-730-7200 P/T 1 (SP, PE, TA) U

Dental Ctr of Highland Park #0000345807 N Figueroa St 323-982-0999 P/T 2 (SP) U

Dental Ctr of W Los Angeles #0165741964 Westwood Blvd Ste 145 310-474-5575 F/T 1Dental Pros #011114906 N Vermont Ave 323-953-7700 P/T 3 (SP) U

Dentology Family Dentl & Braces #01854611444 W Wash Blvd Ste B 310-572-6167 F/T 1 P/T 2 (SP, PE)Devang Gandhi Dental Corp #3533012500 W Florence Ave 323-750-2082 F/T 1 (HI, SP) U

Dr Makar Family Dentistry #0124703875 Wilshire Blvd Ste 1104 213-380-0200 F/T 1 (SP, AR)Dr Mehtas Family Dentistry #0250644576 Whittier Blvd 323-261-0369 F/T 1 (HI, SP)Dr Namian Family Dentistry #001749609 S Atlantic Blvd 323-980-9768 F/T 1 P/T 1 (PE, SP) U

Dr Tsolakyans Dental Office #0015093161 Los Feliz Blvd 323-663-2606 F/T 2 (AM, PE, RU, SP) U

East Los Angeles Fmly Dntstry #0183694410 Whittier Blvd 323-881-0881 P/T 1 (SP)Eastern Dental Center #0214403346 N Eastern Ave 323-227-1800 P/T 1 (SP, CH, VI)Elyson And Assili #382501745 S Kern Ave 323-263-2125 P/T 2 (SP) U

Emily Lee, DDS #3660013756 Sta Rosalia Dr Ste 200 323-299-2994 F/T 1 (SP)Excel Dental Care Inc #0313983980 Glenfeliz Blvd 323-663-2050 P/T 2 (AM, RU, SP) U

Family Dental Care #02519012012 W Washington Blvd 310-390-7981 F/T 1 (SP, AR)Farid Pakravan, DDS., Inc #3283012604 S Vermont Ave Ste 109 323-731-3333 F/T 1 P/T 1 (SP) U

First Family Dental Group #0248223460 Wilshire Blvd Ste 104 213-383-3460 P/T 1 (KO, SP)Florence Compton Dental Group #1847017110 Compton Ave 323-585-5588 F/T 1 P/T 1 (RU, SP) U

Florence Dental Group #0337971575 E Florence Ave Ste A 323-537-4121 F/T 1 (PE, SP) U

Forever Smile Dental Care #0215026200 Wilshire Blvd Ste 1604 323-634-9004 P/T 1 (PE, SP, HE) U

Fred Nayssan, DDS #00232610350 Sta Mon Blvd Ste 190 310-557-1704 F/T 2 (SP) U

Gentle Care Dental Inc #2283013500 Whittier Blvd Ste 101 323-264-8834 F/T 1 (SP) U

Gentle Family Dentist #0276945207 Whittier Blvd 323-269-0266 F/T 2 (SP) U

Gewaid Professional Dtl Corp #010260231 W Vernon Ave Ste 107 323-233-5906 F/T 1 (AR, SP)Green Dental #0281443054 W 8th St Ste 106 213-387-2864 F/T 1 (SP, KO) U

Happy Dental Care #0112935534 York Blvd 323-344-0444 F/T 2 (AM, PE, SP)Hasmik Ambartsumyan, DDS #0175295222 1/2 W Sunset Blvd 323-666-2222 F/T 1 (AM, RU) U

Hengameh Anaraki, DDSInc #0223943875 Wilshire Blvd Ste 901 213-383-2700 F/T 1 (SP, PE)Highland Park Dental Group #1210015740 1/2 York Blvd 323-257-0915 F/T 1 P/T 1 (RU, SP)Hollywood Family Dentist #0287118205 Sta Mon Blvd Ste 12 323-650-1001 F/T 2 (AM, RU, SP)

Hollywood Smile Dental Center #3752018182 W Sunset Blvd Ste 202 323-654-1100 F/T 1 P/T 1 (GE, RU, SP) U

Hollywood Vine Dental Office #0019155280 Hollywood Blvd 323-469-9169 P/T 1 (AM, RU, SP)Ida Ganapolsky, DDS #0086883356 E Olympic Blvd 323-269-5221 F/T 1 (RU, SP)Impressive Dental Center #0162021435 S Vermont Ave 213-739-3096 P/T 1 (SP, HI)James Black, DDS #0059013015 Crenshaw Blvd 323-731-0801 F/T 4 (KO, SP) U

Jeffrie Maneepetasut, DMD Inc #0203214606 Hollywood Blvd Ste B 323-663-3850 F/T 1 (SP, TH)Jocelyn Capistrano, DDS #002866628 N Vermont Ave Ste 5 323-644-3650 F/T 1 (TA)John M Legaspi, DMD #0185946075 S Vermont Ave 323-758-3131 P/T 1 (SP, TA)Kais Chebbi DDSInc #0248125877 S Vermont Ave 323-759-1523 F/T 2 P/T 1Kenneth Chang, DDS #2199014026 W Olympic Blvd 323-930-1744 F/T 1 (SP)Keromina Dental Office #0023324777 Fisher St 323-268-3395 F/T 1 (SP, AR)Khashayar Khodadadi, DDS #02951711900 S Avalon Blvd 323-834-0100 P/T 1 (SP, PE) U

Krest Family Dental #3C54018740 S Sepulv Blvd Ste 130 310-410-9494 F/T 1 P/T 2 (EI, SP, TA) U

La Brea Family Dental #0321873400 S La Brea Ave 323-734-2284 P/T 2 (KO, SP) U

La Paz Clinic #0189531107 S Alvarado St Ste 102 213-380-9999 F/T 3 (HE, PE, SP) U

Ladera Dental Group #0185935814 Rodeo Rd 310-836-7200 F/T 1 (FR, HI, SP)Le Chic Dentist #0267793755 Sawtelle Blvd 310-398-5400 F/T 1 P/T 1 (SP, PE) U

Leslie Laddaran, DDS #3562012105 Beverly Blvd Ste 101 213-484-1288 F/T 2 P/T 1 (SP, TA, CH) U

Lloyd E Stoll, DDS., Inc #0331531828 E Cesar E Chavez Ave 323-268-1805 F/T 1 (SP) U

Manoj Amin, DDS #3455012613 W Sunset Blvd 213-484-1845 F/T 1 U

Manuel Lazo Jr., DDS #0146153827 W Sunset Blvd Ste A 323-660-5630 F/T 1 (TA)Maria P Bernardo, DDS #0182594331 W Sunset Blvd 323-660-2011 F/T 1 (SP, TA) U

Mark A Moses, DDS #0260851839 W Imperial Hwy 323-757-1761 F/T 1 (SP)Mark Laska, DDS #0096933460 Wilshire Blvd Ste 210 213-386-3348 F/T 2 P/T 1 (SP, TA, KO) U

Mehrdad Makhani, DDS #3725016200 Wilshire Blvd Ste 1606 323-933-7744 F/T 1 (PE, SP) U

Michael Schneider, DMD #03326610921 Wilshire Blvd Ste 809 310-208-6813 F/T 1 P/T 1 U

Nelson Walker, DDS #3201013756 Sta Rosalia Dr Ste 317 323-290-5340 F/T 1 (SP) U

Newport Dental #0045961155 N Vermont Ave 323-660-8111 F/T 2 P/T 16 (SP, VI) U

Newport Dental #0087273635 E 1st St 323-269-7367 F/T 5 P/T 3 (AR, CH, SP)Normandie Dental Clinic #0214241690 W Adams Blvd 323-730-0924 F/T 1 (SP, RU, AM, KO)

Ojan Ghalchi, DMD #009138281 Columbia Ave 213-483-3020 F/T 1 (PE, SP) U

Parastoo Farhoodi, DDS #3561013169 Barbara Ct 323-876-6440 F/T 1Patrick Clerk, DDS #0422011200 Wilshire Blvd Ste 205 213-481-1252 F/T 1 (SP) U

Personal Dental Office #0148586222 Wilshire Blvd Ste 103 323-933-4444 P/T 1 (PE, RU, SP) U

Pico Dental Group #0122471561 W Pico Blvd 213-251-9994 F/T 1 (SP, PE)Pico La Cienega Dental #0059548530 W Pico Blvd 310-854-6107 F/T 1 (PE, SP, AM)Premier Dental Clinic Inc #0175311115 Colorado Blvd 323-255-4600 P/T 1 (AM, PE, SP)Ramin Ravaei, DMD #0299551835 S La Cnega Blvd Ste 200 310-836-0300 F/T 2 (SP, TA, RU, PE)Ramin Tour DDSInc #006734907 N Virgil Ave 323-661-8384 P/T 1 (SP, PE, TA)Roberto Parra, DDS #023304 279 S Atlantic Blvd # B 323-266-0899 F/T 1 P/T 1 (SP) U

Sami Nouhad, DDS #1754017080 Hollywood Blvd Ste 817 323-466-3541 F/T 1 (AR, FR, SP) U

Santa Clara Dental #028241600 W Manchester Ave Ste 1 323-753-2361 F/T 1 (SP)Santa Monica Dental Assoc #02998311775 Santa Monica Blvd 310-444-1818 F/T 1 (PE, SP) U

Shahram Sayedna, DDSInc #0169081700 Westwood Blvd 310-470-3095 F/T 1 (GE, PE)Shauna Lee, DDS #0027884146 E Olympic Blvd Ste F 323-269-8007 F/T 1 (SP) U

Sid Solomon, DDS #3934011620 Westwood Blvd 310-475-5598 P/T 1 (FR, PE, SP)Silverlake Dental #0136822390 Glendale Blvd 323-913-9900 F/T 1 (SP, AM, PE, TA) U

Smile Makers #024589998 S Robrson Blvd Ste 103A 310-358-1200 F/T 1 (PE, SP) U

Smilecare-Los Angeles #0039511440 W Manchester Ave 323-753-1141 F/T 2 P/T 2 (FR, KO, SP) U

Smiles R Us Dental Care #01257912756 W Washington Blvd 310-574-8574 F/T 1 (SP, PE)St George Dental Clinic #0064716767 W Sunset Blvd Ste 25 323-469-8816 P/T 1 (RU, SP, AR) U

Steven Stanley, DDS #3729016221 Wilshire Blvd Ste 307 323-931-1446 F/T 1 (RU)Theodore Stomel, DMD #0143286333 Wilshire Blvd Ste 208 323-653-1300 P/T 2 (RU, PE)Total Care Dental & Ortho #0268455703 S Vermont Ave 323-751-5600 F/T 2 P/T 2 (SP) U

United Family Dental Group #1980015109 Whittier Blvd 323-265-2222 F/T 1 (SP, PE) U

Universal Care Dental #1276011111 W 6th St Ste 120 213-895-0009 F/T 4 P/T 4 (SP, TA) U

Universal Care Dental #0280152839 N Eastern Ave 323-987-1020 F/T 3 P/T 3 (SP, VI)Venice Dental Group Inc #00521012456 Venice Blvd 310-390-2423 F/T 2 (AR, SP)Vermont Dental Care #0122098914 S Vermont Ave 323-750-3370 F/T 1 P/T 1 (PE, SP)Vermont Dental Grp Implnt Ctr #012342732 S Vermont Ave 213-386-3366 F/T 1 (KO, SP, TA) U

Victoria Olshansky, DDS., Inc #0165021136 N Fairfax Ave 323-650-6936 F/T 1 (PL, RU)Villacis Dental Corp #02923012027 Venice Blvd Ste A 310-313-5150 P/T 1 (SP)Warren Gerosa, DDS #0170978540 S Sepulv Blvd Ste 1212 310-645-2886 P/T 1 U

Watts Healthcare Corporation #32850110300 Compton Ave 323-357-6600 F/T 1 P/T 1 (SP) U

West Coast Dental #0090171423 E Gage Ave Ste A 323-983-4000 P/T 1 (PE, SP) U

West Coast Dental #0158315162 Whittier Blvd 323-415-6161 P/T 1 U

West Coast Dtl Grp 6th Street #0175341725 W 6th St 213-413-5151 P/T 1 (SP) U

Westwood Dental #02149510884 Sta Mon Blvd Ste 401 310-446-4410 F/T 1 (PE, SP) U

Westwood Dental Care #02825410921 Wilshire Blvd Ste 601 310-208-8551 F/T 1 U

Westwood Smile Design #03349512301 Wilshire Blvd Ste 20 310-207-0606 P/T 1 (PE, SP) U

Westwood Village Dental #023825 951 Westwood Blvd 310-824-2225 F/T 1 P/T 1 (SP) U

Whittier Dental Group #0017472901 Whittier Blvd Ste B 323-526-1992 P/T 2 (PE, SP) U

William Faulkner, DDS #1835015870 Crenshaw Blvd Ste 513 323-292-0231 F/T 1 (SP) U

William Ginzburg, DDS #0C72013130 S Sepulveda Blvd Ste D 310-268-0646 F/T 1 (SP) U

Wilshire Center Dental Group #0445013932 Wilshire Blvd Ste 100 213-386-3336 F/T 6 P/T 4 (SP) U

Wilshire Dental Care, #0103446200 Wilshire Blvd Ste 1508 323-938-6137 F/T 1 P/T 2 (RU, SP, TA) U

Wilshire Dental Group #0124406200 Wilshire Blvd Ste 1104 323-525-1819 F/T 1 (RU, AM, PE, CH)Wilshire Smile Studio Dtl Grp #0016646200 Wilshire Blvd Ste 1609 323-937-5773 F/T 1 P/T 1 (PE, TA) U

Winnie Tan, DDS #0061892621 E 1St St 323-268-9386 F/T 1 (JA, SP)Woodside Dental #00254010921 Wilshire Blvd Ste 505 310-824-0055 F/T 1 P/T 2 (PE, SP, TA)Yiwen Liu, DDS #02465711103 Venice Blvd 310-559-9191 F/T 1 (SP, CH)LYNWOODCristina Rodriguez, DDS #0215063737 Mlk Blvd # 375 310-639-9191 F/T 1 (SP)Pacific Smiles Dental Center #0098633150 E Imperial Hwy Ste 200 310-608-7777 F/T 1 P/T 3 (AM, EI, SP) U

Universal Care Dental #3C43013680 E Imperial Hwy Ste 100 310-761-8100 F/T 6 P/T 7 (EI, SP, TA, VI) U

West Coast Dental #0042039910 Long Beach Blvd Ste A 323-563-8900 P/T 1 (SP) U

MANHATTAN BEACHManhattan Beach Dentistry #2C2701500 S Sepulveda Blvd Ste 210 310-372-8188 F/T 1 P/T 1Manhattan Village Dental Grp #2C14011200 Rosecrans Ave Ste 210 310-414-0620 P/T 1 (SP) U

MARINA DEL REYMarina Dental Center #11150113155 Mindanao Way 310-821-2611 F/T 1 (RU, TA, SP, VI) U

Marina Dentistry Inc #0214024292 Lincoln Blvd 310-578-5000 F/T 1 P/T 2 (PE, SP, TA) U


Banking information: Checking account Savings account Credit union account

Routing Transit Number (RTN):

Account number:

Branch name________________________________________________________ Branch number ______________________________________

Telephone number ( ) —

Automatic Payment Authorization — Please enclose a voided check or preprinted deposit slip from the account checked.

I (we-hereby authorize Delta/Wolfpack Insurance Services, Inc. to charge the applicable monthly dues for 12 months of dental coverage to my account designated above. I understand that coverage will become and remain effective only if there are sufficient funds at the time of the deduction. I agree to comply with the terms as outlined in the combined evidence of coverage and disclosure form. This authority is to remain in full force and effect until I notify Delta Dental in writing 30 days prior to termination. (My bank is authorized to make corrections if any should be necessary.)

Signature of enrollee ____________________________________________________________________ Date ________________________________________

Signature of spouse _____________________________________________________________________ Date ________________________________________

The first two numbers of the RTN must be 01 through 12 or 21 through 32.

(Verify this number with your bank)

29

James Smith 221122 Main St. 15-0000/0000Anyplace, NY 10000 ______________________ 20 _______

PAY TO THEORDER OF Wolfpack Insurance Services, Inc. $ DOLLARS

ANYPLACE BANKAnyplace, NY 10000For

1: 250000005 1 :2000000 86

(Please enclose a voided check or preprinted deposit slip from the account checked.)CHECKS OR MONEY ORDERS MUST BE PAYABLE TO WOLFPACK INSURANCE SERVICES, INC.

Attach check here

RTNNOTE: Staple the check in this space. Use only a check from the account that corresponds to the banking information above.Payment instructions: Payments are due retroactively to the month you and/or dependents enrolled in the Kaiser Federal Employee Dental Plan plus one month in advance. After payment and application are received, the first automatic payment will occur on the 10th of the following month and each month thereafter.

8

AUTOMATIC PAYMENT AUTHORIZATION La Jolla Dental Arts #0132827540 Fay Ave 858-729-9808 F/T 1La Jolla Dental Group #0052958950 Villa Lj Dr Ste B120 858-455-9614 P/T 1La Jolla Village Dental #0239568950 Villa Lj Dr Ste B207 858-558-3490 F/T 1Renaissance Dental Center #0167234150 Rgnts Park Row Ste 130 858-453-2070 F/T 1 P/T 2 (SP)LA MESAGentle Dental-Grossmont #2667015565 Grsmnt Ctr Dr Ste 459 619-464-3383 F/T 5 P/T 4Great Smiles of La Mesa #0244275208 Jackson Dr Ste 108 619-466-4448 P/T 2 U

La Mesa Family Dental #3C14015680 Lake Murray Blvd Ste B 619-465-3393 F/T 1La Mesa Family Dental Center #0057348881 Fletcher Pkwy Ste 325 619-697-2800 F/T 1 P/T 2 (SP)Lake Murray Dental Group #0161585308 Lake Murray Blvd Ste C 619-464-4411 P/T 1 (SP) U

Smilecare-La Mesa #0031675601 Grsmnt Ctr Dr Ste 120 619-462-2272 F/T 1 P/T 5 (SP)LA MIRADABest Care Dental #01385515651 Imperial Hwy Ste 206 562-947-2559 F/T 1 P/T 1 (SP, KO) U

Bright Dental #01792512675 La Mirada Blvd Ste 315 562-944-4745 F/T 1 P/T 1 (SP) U

Eynald Duarte, DDS #02560713960 Valley View Ave 562-944-8244 F/T 1Imperial Dental #00249315769 Imperial Hwy 562-902-9898 F/T 2 (SP, AR) U

John Westermeyer, DDS #05850111900 La Mirada Blvd Ste 7 562-947-3761 F/T 1 (SP)La Mirada Family Dental #17530113922 Imperial Hwy 562-926-7025 F/T 1 P/T 1 (SP)La Mirada Family Dentistry #02715215071 Imperial Hwy 562-947-7000 P/T 2 (AM, SP) U

Magdy & Alina Gad #35940112252 La Mirada Blvd 562-943-0151 P/T 2 (SP) U

New Age Dental #01276014545 Telegraph Rd 562-777-1188 F/T 1 (SP, PE) U

LA PALMALicauco-Tan Dental Corp #34750130 Centerpointe Dr Ste 10 714-994-0888 F/T 2 (SP, TA) U

LA PUENTEAmerican Dental Care #0312051206 N Hacienda Blvd 626-917-8630 F/T 1 (CH, SP) U

Fairgrove Family Dentistry #03143615260 Fairgrove Ave 626-968-4733 P/T 1 (CH, SP, Vi)La Puente Village Dentistry #002085401 S Azusa Ave Ste A 626-810-8222 P/T 1 (SP)Vijay Pharar, DDS #00382317311 Valley Blvd # D 626-810-2444 F/T 1 (SP) U

LA QUINTABright Now! Dental #01923079255 Highway 111 Ste 1 760-771-1200 F/T 2 P/T 7 (SP) U

La Quinta Dental Group #00063178595 Highway 111 Ste 300 760-771-0300 F/T 2 (CH, SP)LA VERNEDental Care of La Verne #1727012323 Foothill Blvd 909-596-1861 P/T 1 (CH, SP) U

Enayda Enabe, DMD #0239092025 Foothill Blvd # B 909-593-1347 F/T 1 (SP, TA)

Laverne Dental Group #0064232216 Foothill Blvd 909-392-3899 F/T 1 P/T 2 (SP) U

LAGUNA BEACHJoseph Levingston, DDS., Inc #024253385 N Coast Hwy 949-494-7115 P/T 1 (SP)Laguna Beach Dental Group #00150331796 Coast Hwy 949-415-1020 P/T 1 (SP) U

LAGUNA HILLSAida Shahangian, DDS #02995623961Cle De La Magdalena 431 949-588-7525 F/T 1Akash Lapsi, DDS #02891323521 Paseo De Valencia 300 949-770-7766 F/T 1 U

Brilliant Smile #01494123024 Lake Forest Dr Ste A 949-716-7166 F/T 1 (GE, PE, SP) U

Duc Vu, DDS #00189023595 Moulton Pkwy Ste I 949-454-0499 P/T 1 (SP, VI) U

Farshad Saghatchi, DDS #01706526534 Moulton Pkwy Ste D 949-831-8100 P/T 1 (PE, PL, SP) U

Flora Simtchera, DDS #03112724022 Calle De La Plata #450 949-830-0074 P/T 3 (CH, PE, SP, TA)Oakbrook Dental Center #00952824351 Avenida De La Carlota 949-951-7800 F/T 1OC Dental Group #03061525401 Alicia Pkwy Ste J 949-587-3010 P/T 1 (PE, SP) U

Ruxanda Ghibu, DDS #3C010124401 Ridge Route Dr # A107 949-588-2112 F/T 1 (SP)S C Dental Care #00494122972 Moulton Pkwy Ste 106 949-770-3010 P/T 1 (FR, SP) U

LAGUNA NIGUELChoice Dental Care #01479230262 Crown Valley Pkwy # E 949-363-0018 F/T 1 (AR, FR, PE, SP, TR)Dental 2000 #03053230012 Crown Valley Pkwy # B 949-495-2866 P/T 1 (HI, PE, SP) U

Laguna Niguel Dental Group #00192527901 La Paz Rd Ste D 949-389-9195 P/T 2 (SP, VI) U

Rancho Niguel Dental Group #170601 30140 Town Center Dr 949-249-4180 F/T 3 P/T 1 (SP, VI)Sea Country Dental #1C270132341 Golden Lantern Ste B 949-496-7910 F/T 2 P/T 1 (GE, VI)Sobhi Batniji, DDS #30480130231 Golden Lantern Ste D 949-363-1200 P/T 1 (Ar, Fr)LAGUNA WOODSChristine Chung, DDS #1C810124310 Moulton Pkwy Ste C1 949-859-3988 F/T 4 (PE, SP, VI)Leisure Dental #01493424102 El Toro Rd Ste A 949-830-6510 F/T 1 P/T 1 (AR, CH, HI, VI) U

LAKE ELSINORECanyon Lake Dental #02289725321 Railroad Canyon Rd 951-244-2311 F/T 1 (SP) U

Elsinore Hills Fmly Dentistry #00254731500 Grape St Ste 8 951-471-1628 P/T 1 (SP) U

Lake Elsinore Dental Group #18740132235 Mission Trl Ste 8 951-674-6808 F/T 1 (SP)Marketplace Dental Group #01532729273 Central Ave Ste A 951-245-8664 F/T 1 P/T 1 (SP) U

Oak Grove Dental Group #01777818285 Collier Ave Ste B 951-471-0034 P/T 2 (SP) U

Tuscany Dental #161201361 Railroad Canyon Rd Ste A 951-471-1400 P/T 1 (AR, SP, RO) U

LAKE FORESTDimension Dentistry #00059520671 Lake Forest Dr # B103 949-458-2582 F/T 1 (GE, SP, VI) U

Heritage Dental Group #01752522373 El Toro Rd 949-951-5503 P/T 2 (CH, JA, SP) U

Lake Forest Dental Group #0C480123704 El Toro Rd Ste A 949-770-9355 P/T 1 (SP) U

Lake Forest Dentistry #03104120025 Lake Forest Dr Ste 105 949-595-4322 F/T 2 (PE, VI) U

Marina Dental #01327823591 El Toro Rd Ste 130 949-597-8808 F/T 1 U

Morgan Dental #02891623572 El Toro Rd Ste E 949-206-9000 P/T 1 U

Smilecare Dental Group #01334723622 Rockfield Blvd 949-837-2766 F/T 1 P/T 4 (SP) U

LAKEWOODD and D Dental Office #0132234180 Woodruff Ave 562-938-9514 F/T 1 P/T 1 (VI, SP) U

David Goren & Assoc #2106015203 Lakewood Blvd 562-531-7373 F/T 2 (SP) U

Jiten Vasa, DDS #32920111455 Carson St Ste E 562-860-7116 F/T 1 (SP, HI)Lakewood Cerritos Dtl Ctrs #0336705819 Adenmoor Ave 562-804-2296 F/T 1 (SP, TA) U

Lakewood Dental Arts #0529015555 Del Amo Blvd 562-866-1735 F/T 3 (SP)Lakewood Plaza Dental Group #0158364346 South St 562-408-3500 P/T 6 (KO, PE, SP) U

New Smile Dental Care #02152521012 Norwalk Blvd 562-860-8828 P/T 2 (KO, SP)LANCASTERAlex Buznikov, DDS Corp #0283141331 W Avenue J Ste 201 661-645-1019 P/T 1 (SP, RU, PL)American Bright Dental #00233644810 Elm Ave 661-945-2645 F/T 1 (SP)Boyadjian/Matossian Dtl Corp #01853643845 10th St W Ste 1A 661-948-9646 P/T 1 (AM, TA, SP, PE, RU) U

Bright Now Dental #02113243456 10th St W 661-945-2900 F/T 1 P/T 12 (SP) U

Desert Breeze Dental Care #0135221340 W Avenue J 661-942-1474 P/T 1 (SP)Elite Dental Care #02462644439 North 17T St W #201 661-723-1461 P/T 2 (SP, KO) U

Family Dental Practice #02389944558 10th St W 661-723-1111 F/T 2 P/T 1 (SP)Golden Dental #030150803 W Avenue J 661-948-8100 F/T 1Hi Desert Dental Center #0018191745 W Avenue K Ste C 661-723-5400 F/T 1 P/T 2 (RU, SP, TA) U

Honping Wong, DDS #02781144439 17th St W Ste 103 661-949-0390 F/T 1Kamram Saidara, DDS #3785012030 W Avenue J 661-949-6757 F/T 2 (SP, PE)Smilecare-Lancaster #0015051228 W Avenue K 661-949-1970 F/T 1 P/T 2 (SP) U

LAWNDALEAll Smile Dental Care #02456115228 Hawthorne Blvd 310-679-8000 F/T 1Bay Dental #01288716910 Hawthorne Blvd 310-542-4333 F/T 1 P/T 1 (HI, SP)Hanna Dentistry #01351814314 Hawthorne Blvd 310-676-6400 F/T 2 (AR, SP) U

Henry S Lee DDS #0177474181 Redondo Beach Blvd 310-371-6513 P/T 1 (SP)

Lawndale Dental #02026716128 Hawthorne Blvd 310-370-4511 F/T 3 P/T 10 (SP, TA) U

Maged Nessim, DDS #01750915655 Hawthorne Blvd # A-B 310-675-7111 F/T 1 P/T 2 (AR, SP, TA) U

LEMON GROVEGrove Dental Group #2C78017733 Palm St Ste 105 619-464-7099 P/T 1 (SP)Smileburst Dentistry #2 #0210087040 Broadway # A27 619-667-1088 F/T 1 P/T 2 (SP, TA) U

Loma Linda Bruce Taber, DDS #14830125835 Barton Rd Ste 104 909-796-2299 F/T 2 (KO, RU, SP) U

LOMITAA Dentistry #0018981816 Lomita Blvd 310-326-4117 P/T 1 (KO, SP) U

Narinder Uppal, DDS #13150125107 Narbonne Ave 310-539-8392 F/T 1 (SP) U

Pch Dental #0C61012207 Pacific Coast Hwy 310-534-2633 F/T 1 (SP) U

Shannon Yoon, DDS #00885825124 Narbonne Ave Ste 202 310-530-3260 F/T 1 (SP)LONG BEACHAccu Dental Group #0189766413 E Spring St 562-938-8388 P/T 1 (SP, VI) U

Alan Grant, DDS #0805013620 Long Beach Blvd Ste B6 562-426-6458 F/T 3 P/T 1 (SP, TA, KO) U

Atlantic Dentistry & Braces #0177483530 Atlantic Ave Ste 103 562-988-2700 F/T 2 P/T 1 U

Bashar Komoc, DDS #0245633318 E Anaheim St 562-986-5570 F/T 1 (GE, SP)Beautiful Smiles Dental Care #0116751729 Termino Ave 562-494-8400 P/T 2 (SP) U

Bixby Knolls Dental Group #0196063903 Long Beach Blvd 562-427-2478 F/T 1 P/T 2 (SP, TA, PE)Bondades Family Dental Office #0320416950 N Paramount Blvd 562-531-9711 F/T 1 P/T 2 (HI, SP)Carson Dtl & Cosmetic Ctr #0336741200 E Carson St Ste 300 562-988-7788 F/T 1 (SP) U

Donna Marie Calima, DMD #002517389 Redondo Ave 562-621-9796 F/T 1 (SP, TA) U

Dr Campbell/ Century Dental #0172182211 E 7th St 562-439-6562 F/T 2 P/T 1 (SP, VI) U

E Dental #0264624301 Atlantic Ave Ste 4 562-426-9308 P/T 1 (SP, KO)Family Dental Care #0C63011327 Long Beach Blvd 562-218-5555 F/T 1 P/T 1 (SP, HE) U

Firoz Hakakha, DDS #0C62011183 E Anaheim St 562-599-6600 F/T 1 P/T 1 (SP, HE) U

Gary Trombatore, DDS #0301683840 Woodruff Ave Ste 104 562-425-0545 F/T 2Jasbir Batra DDSInc #000901925 E San Antonio Dr Ste 10 562-428-4678 P/T 1Knolls Dental Group #3883013932 Long Beach Blvd # A 562-427-3890 P/T 1 (SP) U

Kosal Kom, DDS #0126822338 E Anaheim St Ste 108 562-434-9980 F/T 1 (VI)Long Beach Dental Arts #0056106226 E Spring St Ste 200 562-421-3336 P/T 1 (SP) U

Long Beach Dental Group #007631659 Redondo Ave 562-439-0494 F/T 1 P/T 1 (SP)Long Beach Dental! #019416308 Orange Ave 562-436-4214 P/T 1 (SP)

Maged Zaky Nessim DDS., Inc #0028643440 Atlantic Ave Ste 2 562-424-0724 P/T 1 (AR, SP)Mark Cocchi, DDS #3592012865 Atlantic Ave Ste 119 562-426-0778 F/T 1 (GE, IT, SP)Newport Dental #0236483383 Long Beach Blvd 562-424-1600 F/T 2 P/T 8 (SP) U

Omega Family Dental #015864816 W Willow St 562-595-7077 F/T 1 (CH, VI, SP) U

Shamanna Mohan, DDS #0019225399 Orange Ave 562-422-9698 F/T 1 (SP)United Family Dental #000633141 E Willow St Ste P 562-988-2888 F/T 4 (PE, SP, TA, RU) U

Universal Care Dental #1278012360 Pacific Ave 562-595-0731 F/T 6 P/T 8 (SP, VI) U

Universal Care Dental #0027923325 Palo Verde Ave Ste 208 562-429-1642 F/T 3 P/T 5 (SP, TA, VI)Victor De Los Santos, DDS., Inc #0133333712 Atlantic Ave Ste C 562-426-1298 F/T 1 P/T 2 (SP)Village Dental Center Bldg #0840014200 N Lakewood Blvd 562-420-1701 F/T 2 (SP) U

LOS ALAMITOSAshokkumar Mehta, DDS #28340110900 Los Alamitos Blvd 562-596-8888 P/T 2 U

Enhance Dental #0256874300 Katella Ave 562-799-8300 F/T 1 (KO, SP) U

Los Alamitos Dental Arts #1877013724 Katella Ave 562-936-0071 F/T 1 P/T 1Michael Mcwalters, DDS., Inc #0116363662 Katella Ave Ste 206 562-598-7914 P/T 1 (SP) U

LOS ANGELESAdelaida Quingco, DDS #0031531127 Wilshire Blvd Ste 1103 213-250-3998 F/T 1 (SP, TA) U

Adonis Regala Fam Dentistry #0116864065 Whittier Blvd Ste 201 323-268-3877 F/T 1 (SP, TA)Afar & Ghasri Dental Corp #0221036221 Wilshire Blvd Ste 303 323-931-2000 P/T 2 (SP, RU, PE)Afshin Golyad, DDS #01657012340 Sta Mon Blvd Ste 241 310-820-7010 P/T 1 (TA, PE, SP) U

Afsoon Gerayli, DDS., Inc #02167810921 Wilshire Blvd Ste 409 310-824-2624 F/T 1 (PE) U

Airport Center Family Dental #0075385304 W Century Blvd 310-215-1455 P/T 1 (SP) U

Alegria Dental Center #0295474214 Beverly Blvd Ste 209 213-384-8400 F/T 2 (AM, AR, RU, SP, TA) U

Alex Buznikov, DDS Corp #02814511600 Wilshire Blvd Ste 10 310-415-1649 F/T 1 (PL, RU, SP) U

Ali Khosrovani DDS #0238904905 York Blvd 323-255-8774 F/T 1 (AM, PE, SP)Alina Oganyan, DDS., Inc #0028681727 N Vermont Ave Ste 109 323-644-3366 F/T 1 (AM, RU) U

Alvarado Family Dental Center #003544811 S Alvarado St 213-383-3314 P/T 2 (SP) U

American Dental #0245462033 E Florence Ave 323-583-8896 P/T 1 (RU, SP)American Dental #0245502716 N Broadway Ste 214 323-221-5931 P/T 1 (SP, RU)Amy Iwata, DDS #0124413756 Sta Rosalia Dr Ste 504 323-293-2600 F/T 1 (SP, JA) U

Anthony Milanez, DDS #0137875670 Wilshire Blvd Ste 1710 323-931-9019 F/T 1 U


To enroll in the KPIC DENTAL insurance plan, please complete the enrollment form in this brochure (page 7-and enclose the first month’s payment (payable to Wolfpack Insurance Services, Inc.). Return the enrollment form and the first month’s payment by December 21, 2010 to:

Wolfpack Insurance Services, Inc.P.O. Box 720Belmont, CA 94002-0720

Make checks payable to Wolfpack Insurance Services, Inc.

Staple your check in the space provided on this form. Use only a check that corresponds to the banking information you have provided.

Payment instructions: Payments are due retroactively to the month you and/or dependents enrolled in the Kaiser Federal Employee Dental Plan plus one month in advance. After payment and application are received, the first automatic payment will occur on the 10th of the following month and each month thereafter.

Remember —

• If you are currently a member of Kaiser Permanente, please include a copy of your Kaiser Permanente ID card.

or

• If you are now enrolling in Kaiser Permanente, please include a copy of your Medical Enrollment Form (Form 2809).

928

n WHO CAN JOIN

As a Federal member of Kaiser Permanente, you are eligible to join the DeltaCare USA program.

Your eligible dependents include your lawful spouse and unmarried children under 26 years old, including stepchildren and children placed with you for adoption or foster care. An unmarried child 26 years of age or older may continue to be eligible as a dependent if incapable of self-support because of physical handicap or mental retardation that commenced prior to age 26, provided that the person is legally residing with and dependent upon the eligible member, and Delta Dental receives notice of the disability.

n EMERGENCY SERVICES Dental emergencies are covered up to a maximum of $100.00 per

emergency.

n NO CLAIM FORMS The dental location you choose provides all primary dental

services. There are no claim forms to complete or percentage of usual charges for you to pay.

n NO DEDUCTIBLES With the DeltaCare USA program, there are no required

deductibles to pay, so your benefits begin immediately.

n NO DOLLAR LIMIT OF DENTAL BENEFITS No annual maximum.

n PRE-EXISTING CONDITION RESTRICTIONS Pre-existing conditions are not excluded in the DeltaCare USA

program. Exception: work in progress.

n PREPAID PROGRAM SAVES ON DENTAL COSTS Your out-of-pocket savings could be substantial. You know the

exact cost prior to treatment, allowing you to predict future dental expenses.

When you enroll in this program, you are enrolling for a period of one year. This does not apply if your employment is terminated.

n QUALITY REVIEW OF DENTAL PROVIDERS On-site audits of participating dental locations ensure that

established standards of quality are maintained.

n SPECIALTY SERVICES The DeltaCare USA program offers services in dental specialty

areas. These include periodontics (treatment of diseased gums and bone), endodontics (root canal therapy) and oral surgery procedures. Sepcialty services must be referred by the assigned network dentist and preauthorized, in writing by Delta Dental. If an enrollee is assigned to a dental school clinic for specialist services, those services may be provided by a dentist, a dental instructor, a clinician or a dental student under the supervision of a dentist.

The DeltaCare USA program provides all reasonable and customary dental care (subject to the provisions, limitations and exclusions shown in the Combined Evidence of Coverage and Disclosure Form) if care is provided by your assigned network dentist.

One of your non-FEHB Dental benefit options, DeltaCare USA, is administered by Delta Dental of California.

With DeltaCare USA, you select a conveniently located network dentist to provide dental care for you and your family. You pay a small copayment or, for some services, no copayment. There are no deductibles and no claim forms to worry about.

The dues for 2011 are listed below:

NOTE: This is only a brief summary of the program. An Evidence of Coverage stating the terms of your program will be sent to you upon enrollment.

These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are made available to all enrollees and family members of this Plan.

Dues* Monthly* Quarterly*

Self Only $ 11.89 $ 35.67 Self & One Party $ 19.90 $ 59.70 Self & Two or More $ 30.17 $ 90.51 *Good through December 31, 2011.

Please read the following information so you will know how to get dental care under the

DeltaCare USA program.

n About DeltaCare USA

The DeltaCare USA program is an HMO dental plan that focuses on preventing dental problems and assuring the delivery of quality dental care.

Delta Dental has contracted with a network of dental offices. A listing of these offices is included for you in the back of this brochure, or you may go to www.deltadentalins.com to search for a conveniently located network dentist. The network of dental offices is composed of established dental practices.

DeltaCare® USAJerry Kolesar, DMD #3657011122 N Brand Blvd Ste 102 818-242-2667 F/T 2 (SP)\John Gazarian, DDS #171801230 N Maryland Ave Ste 205 818-502-9990 P/T 1 (AM, PE, SP, TA, RU) U

John Yekikian, DDS #2359011128 N Brand Blvd Ste A 818-242-4703 F/T 1 (SP, AM)Khodaverdian Njdeh, DDS #030036428 Arden Ave Ste 100 818-547-4020 F/T 2 (AM, PE) U

Melineh Arakelian, DDS #013063411 N Central Ave Ste 120 818-956-7137 F/T 1 (AM, PE, SP) U

Montrose Dental Group #3C46013600 Ocean View Blvd Ste 6 818-541-9010 F/T 2 (AM, PE, RO)New Smile Dental Group #012588204 E Chevy Chase Dr Ste 1 818-547-4398 P/T 1 (AM, RO, AR, FR, GE, PE)Ovsep Lusinyan, DDS #028263501 W Glenoaks Blvd Ste 14 818-500-7979 F/T 1Prodent Care Dental Practice #030727213 N Orange St Ste F 818-241-3155 F/T 1 (SP, AM, PE) U

Smile Dental Practice #0023751114 E Broadway 818-500-7740 F/T 1 (AM, PE, RU) U

Starlight Dental Group #028405214 N Central Ave 818-243-8888 F/T 1 (AM, SP, PE, RU)Teeth & Gums Central Dntistry #018577730 S Central Ave Ste 116 818-545-3515 P/T 1 (TA) U

Town Center Dentistry #013449316 E Broadway Ste A 818-548-7700 F/T 1 (AM, SP, TA) U

Zareh Baghoomian, DDS #0110961010 N Glendale Ave Ste 206 818-548-0752 F/T 1 (AM, PE) U

GLENDORAFriendly Dental Care #030531335 W Arrow Hwy 626-914-6663 F/T 1 (AR, SP, PE, TA) U

Glendora Dental Center #288401130 W Route 66 Ste 316 626-335-7727 F/T 1 (TA, SP, PE)Glendora Smiles Dental #021055605 W Route 66 626-771-1320 F/T 1 P/T 1 (SP, PE, GE, FR) U

Harry Pages, DDS #191001641 W Route 66 Ste D 626-914-3068 F/T 1 (SP) U

Lone Hill Dental #0192721331 S Lone Hill Ave Ste 185 909-305-1015 P/T 1 (SP, VI) U

Shawky Soliman, DDS., Inc #013849150 S Grand Ave Ste F 626-914-3150 F/T 1 (AR, SP) U

Smile Bright #0325951814 E Route 66 Ste B 626-963-7000 F/T 1 (SP) U

Woodglen Dental Center #016959220 S Glendora Ave Ste B 626-914-4054 P/T 1 (AR, SP)GOLETAGoleta Dental Practice #018804164 Kinman Ave Ste B 805-683-7777 F/T 1 (SP, HI)GRANADA HILLSBalboa Dental Group #02051911850 1/2 Balboa Blvd 818-360-1946 P/T 1 (PE, SP) U

Buenaventura Dental Inc #03195016917 Devonshire St 818-360-0957 P/T 2 (TA) U

Buenaventura Dental Inc #03195118121 Chatsworth St 818-360-1500 P/T 1 (TA) U

John Bosak, DMD #320001 10727 White Oak Ave Ste 213 818-368-5676 F/T 2 (PE, SP)Kamran Rafie, DDS #17170110144 Balboa Blvd 818-363-0200 F/T 2 (SP, PE) U

GRAND TERRACEMarileth Coria, DDS #00234122575 Barton Rd 909-825-6003 F/T 1 (SP)

HACIENDA HEIGHTSComfort Smile Fmly Dentistry #2C940115724 Gale Ave 626-333-5244 F/T 1 (CH, SP)Katy Chou Family Dentistry #03083817138 Colima Rd Ste C 626-854-1826 P/T 1 (CH, SP) U

Tri City Smiles Dtl Grp #02380517188 Colima Rd Ste B 626-581-7878 F/T 1 P/T 1 (HI, SP) U

Viola Iskarous, DDS #0126842440 S Hacienda Blvd Ste 233 626-968-0052 F/T 1 (SP)HARBOR CITYBay Harbor Dental Office #2C91011537 Lomita Blvd 310-530-5252 F/T 2 (SP) U

HAWAIIAN GARDENSGentle Dental Care #02385512144 Carson St Ste E 562-982-1380 P/T 1 (SP, KO) U

Keun Chan Lee, DDS #01207312531 Carson St 562-924-2448 F/T 1 (KO, SP) U

Newport Dtl-Hawaiian Gardens #01343421714 Pioneer Blvd 562-421-3737 F/T 2 P/T 6 (HI, SP) U

HAWTHORNEAll Kids Dental Care #03024813340 Hawthorne Blvd 310-973-8004 F/T 1Behdad Omrani, DDS., Inc #02506913637 Hawthorne Blvd Ste 101 310-644-2310 F/T 1 (PE, SP)Castle Dental Centers #01564913220 Hawthorne Blvd 310-679-9019 F/T 2 P/T 10 (SP) U

Choice Dental Group #3C490112730 Hawthorne Blvd Ste D 310-644-4000 P/T 2 (SP, PE, KO) U

Comfort Dental Center #1659014277 W El Segundo Blvd 310-970-0900 F/T 2 (SP, PE) U

Daily Dental Group #02506611633 Hawthorne Blvd Ste 502 310-644-4464 F/T 1 P/T 1 (SP, JA)Dr Gary Gee DDS #01941314115 Crenshaw Blvd Ste 1 310-644-0474 F/T 1 (CA, SP)Hawthorne Dental #01120113935 Hawthorne Blvd 310-973-6428 P/T 1 (SP)Hawthorne Dental Care #0189774477 W 118th St Ste 500 310-970-9255 F/T 1 (SP) U

Hawthorne Fmly & Cosmetic Dtl #00752913402 Hawthorne Blvd 310-675-5050 F/T 1 (SP)John Legaspi, DMD #0C450113352 Hawthorne Blvd 310-973-1525 P/T 1 (SP)Sunrise Dental Group #01294613624 Hawthorne Blvd Ste 205 310-856-6574 F/T 1 (SP)HEMETBright Now! Dental #0168012721 W Florida Ave 951-925-2226 F/T 3 P/T 13 (SP)Gregory Skinner Dental Corp #032178250 S Lyon Ave Ste B 951-658-2354 F/T 1 (SP) U

Hemet Dental Care #0198981300 E Florida Ave 951-765-5544 P/T 1 (SP) U

Hemet Dental Clinic #004077940 E Morton Pl 951-652-2796 F/T 1Hemet Dental Group #0121504000 W Florida Ave 951-658-9980 P/T 2 (SP, AR, FR, HI) U

Hemet Smiles #0220691001 S State St Ste B 951-658-6100 P/T 1 (SP) U

HESPERIABright Now Dental #01851717003 Bear Valley Rd Ste D 760-244-1900 F/T 2 P/T 5 (SP) U

Dental Group of Hesperia #00923815776 Main St Ste 18 760-949-8484 P/T 1 (PE, SP)Desert Valley Dental Grp #39100117247 Main St 760-244-2625 P/T 1 (RU, SP, TA, VI) U

Family Dentistry #02142315550 Main St Ste B7 760-947-7777 F/T 1 (PE, SP, TA) U

Gentle Dental #01368816455 Main St Ste 17 760-244-6077 F/T 4 P/T 3 U

High Desert Smiles Dentistry #02691712821 Main St Ste 150 760-947-9853 P/T 2 (SP)HIGHLANDHighland Dental Group #02740527949 Greenspot Rd Ste H 909-864-6010 P/T 1Inland Dental Ctr Highland #0161356982 Boulder Ave 909-862-2121 F/T 1 P/T 1 (SP) U

HOLLYWOODArnold Rifman, DDS #3890016234 Fountain Ave 323-466-2937 F/T 1 (RU, SP) U

Said Aly, DDS #0159011680 Vine St Ste 1020 323-464-2033 F/T 1 (AM, AR)HUNTINGTON BEACHBeach Dental Group #00309319720 Beach Blvd # B 714-593-1010 F/T 1 P/T 3 (SP) U

Beach Dental Group #0117189842 Adams Ave Ste 106 714-968-4907 F/T 1 P/T 2 (SP) U

Beachside Dental Group #20070118800 Main St Ste 110 714-842-6151 F/T 1 P/T 5 (SP, VI, IT, TA, AR) U

Bella Terra Dentistry #02326516261 Beach Blvd 714-847-2220 F/T 1 (SP, VI) U

Big Dental Group #03094118682 Beach Blvd Ste 100 714-968-3522 F/T 1 P/T 1 (SP, PE, TR) U

Coastline Dental Care #01923616033 Bolsa Chica St Ste 110 714-846-7700 P/T 1 (SP, VI) U

Cosmetic & Dental Implant Ctr #02963419080 Brookhurst St 714-968-2527 P/T 1 (SP, VI) U

Dtl Assoc of Huntington Beach #0113895942 Edinger Ave Ste 101 714-377-4449 P/T 2 (PE, SP, KO, AR) U

Family Dental Care #0295829952 Hamilton Ave 714-593-0256 P/T 1 (SP) U

Harbour Landing Dental #0155814911 Warner Ave Ste 202 714-846-4414 P/T 1 (SP) U

Kathleen Collins, DDS #01722016052 Beach Blvd Ste 120 714-887-0444 F/T 1 (SP) U

Kosmas Pappas, DDS #00741910106 Adams Ave 714-962-7797 P/T 1 (SP) U

Lina Musleh, DDS #00018519754 Beach Blvd 714-964-8830 F/T 1 (SP)Pacifica Dental Group #01730218821 Delaware St Ste 101 714-848-8211 P/T 3 (AR, TA, PE, SP, VI)Pearly White Dental #01189116474 Bolsa Chica St 714-377-3736 F/T 1 (SP, VI) U

Smart Dental #02569016152 Beach Blvd Ste 140 714-847-5100 P/T 1 (AR, SP, TA, KO, CH, VI)Subodh Swaroop, DDS #02413010028 Adams Ave 714-962-4070 F/T 1 (SP)Yorktown Dental Practice #0032099931 Yorktown Ave 714-963-9809 F/T 1 (SP)HUNTINGTON PARKAndrew Shieh DDS and Assocs #0125802563 Zoe Ave 323-588-6384 F/T 1 P/T 1 (CH, SP) U

Belenda V. Abanilla Dental #0130503017 E Florence Ave 323-584-1171 F/T 1 (SP, TA)Binafard Dentaland #0129197136 Pacific Blvd Ste 210 323-585-1000 P/T 1 (FR, PE, SP)Dr Fransis Dental Center #0287126040 Pacific Blvd 323-583-5677 F/T 3 (AR, PE, SP)

Huntington Family Dental #3924012542 E Florence Ave Ste A 323-582-0755 F/T 1 P/T 1 (PE, SP) U

Huntington Park Family Dental #0023762711 E Slauson Ave 323-582-4474 F/T 1 P/T 1 (AR, SP) U

Justin Family Dentist #3761017208 Pacific Blvd Ste 200 323-582-2200 F/T 1 (KO, SP) U

Kids And Adult Dental Care #0126252625 E Florence Ave Ste C 323-277-9191 F/T 1 (PE, SP)Kims Family Dentistry #2702017601 Seville Ave 323-587-6600 F/T 1 (KO, SP) U

Pacific Family Dentistry #0024885914 Pacific Blvd 323-581-0100 F/T 1 (KO, SP) U

Seville Dental Center DDS #3558017705 Seville Ave Ste A 323-582-6938 F/T 1 (SP) U

Your Choice Dental #1582016601 Rugby Ave Ste 400 323-585-1515 P/T 2 (RU, SP) U

Your Chois Dental #0040693131 E Florence Ave 323-585-3332 F/T 1 (KO, SP) U

Huntington ParkPro Dentista #0326412634 Clarendon Ave 323-585-2777 F/T 1IMPERIALPeoples Dental Office #1853012387 US Highway 86 760-353-5100 F/T 2 (SP)IMPERIAL BEACHImperial Beach Dental Group #0245421340 Imprl Bch Blvd Ste 202 619-429-6600 F/T 3 (SP)Luis Contreras, DDS #0165811340 Imprl Bch Blvd Ste 101 619-575-6644 F/T 1 (SP)INDIOGentle Dental Indio #01729381557 Dr Carreon Blvd Ste D3 760-775-5284 F/T 1 P/T 2 (PE, SP, TA)Granada Dental #01750881730 US Highway 111 Ste 8 760-347-7505 F/T 1 (PE, SP)Inland Dental Center #02120244100 Jefferson St # 404 760-772-0214 P/T 1 (SP) U

Lm Rojas Dental Corp #02036344200 Monroe St 760-775-3938 F/T 1 (SP) U

Town & Country Dental #023264 81637 Highway 111 SW #1760-342-1448 P/T 1 (RU, SP, AM) U

INGLEWOODAesthetica Dental Inc #0216773451 W Century Blvd Ste B1 310-330-9000 F/T 2 (Pe, Sp) U

Century Dental/Dr Campbell #008571257 S Market St 310-677-4767 F/T 1 P/T 3 (KO, PE, SP)Comprehensive Dental #030826141 N Prairie Ave 310-330-0080 F/T 1Crown Dental Group #0038221295 S La Brea Ave Ste 101 310-672-0129 P/T 1 (KO, SP) U

Debbie R Ballenger, DDS #033841139 N Prairie Ave 310-412-2994 P/T 1 (SP) U

Emmanuel Okonkwo, DDS #0292022710 W Manchester Blvd Ste 3 323-971-5026 F/T 1Forum Dental Group #228401400 E Regent St 310-674-7590 F/T 1 (SP) U

Imperial Crenshaw Dental Ctr #0027842798 W Imperial Hwy 323-418-8888 F/T 1 (SP, TA) U

Kaufman & Weiner DDS., Inc #0999013516 W Imperial Hwy 310-677-9101 F/T 3 P/T 1 (SP) U

Portia Turner, DDS #005593139 N Prairie Ave 310-412-2994 P/T 1Raymont Johnson Jr, DDS #375501808 E Manchester Blvd 310-671-1234 F/T 1 (SP) U

Westchester Dental Care #030246212 N Market St 310-671-9920 F/T 1 P/T 1 (PE, SP) U

IRVINECalifornia Smile Design #0024102646 Dupont Dr Ste C200 949-955-3366 F/T 1 (AR, IT, RU) U

Dental 2000 #01235533 Creek Rd Ste 210 Bldg B 949-857-6757 P/T 1 (SP, PE, HI) U

Dental Care of Irvine #0130864330 Barranca Pkwy Ste 230 949-786-1234 F/T 1 (HI, KO, SP, PE)Elite Dental Group #0292952500 Alton Pkwy Ste 203 949-861-2500 P/T 1 U

Family Dentistry on The Lake #0258144605 Barranca Prkwy #200 949-551-4336 F/T 1 (SP)Farzad Shaygan, DDS #3399014040 Barranca Pkwy Ste 140 949-559-7300 F/T 1 (PE) U

Gentle Dental #0179144950 Barranca Pkwy Ste 105 949-551-4242 P/T 2 (SP, VI) U

Malek Mansour, DDS #00059616100 Sand Canyon Ave # 330 949-585-1515 F/T 3 (AR, FR, SP) U

Michael Alijani, DDS #02927917655 Harvard Ave Ste F 949-833-8884 F/T 2 P/T 1 (SP) U

OC Dental Group #01989214130 Culver Dr Ste C 949-653-8888 P/T 1 (PE, FR, SP) U

Parkview Dental Group #01491862 Corporate Park Ste 225 949-622-0001 F/T 1 (PE, KO, SP) U

Roya Toomarian, DDS #00246133 Creek Rd Ste 130 949-786-0640 F/T 1 U

United Family Dental #0038145321 University Dr Ste A 949-653-2244 P/T 1 (AR, CH, SP)Walnut Dental Group #01462714427 Culver Dr 949-733-0486 P/T 1 (SP) U

LA CRESCENTACrescenta Family Dental #0070392644 Foothill Blvd 818-248-9988 F/T 1 P/T 1 (Am, Fr, Pe)Family Dentistry #0158413157 Foothill Blvd Ste A 818-541-9724 P/T 1 (AM, SP) U

Nina Sonin, DDS #0188813043 Foothill Blvd Ste 5 818-542-3039 P/T 1 (RU, SP)LA HABRAAkshar Dental #0251751281 E La Habra Blvd Ste 4 562-697-3788 F/T 1 (SP, HI, CH, TH)Chester Jeng DDS., Inc #002721744 W La Habra Blvd 562-691-0738 P/T 1 (SP, CH)Coastal Dental Care #0078811216 S Idaho St Ste C 714-447-8200 F/T 1 P/T 2 (SP, KO) U

Dental One #0228041875 W La Habra Blvd 562-266-0033 F/T 1 (SP, KO) U

Gentle Dental #005462331 N Harbor Blvd 562-694-3511 F/T 3 P/T 1 (SP) U

Harbor Dental Care #0095421150 E Imperial Hwy 714-992-2200 P/T 1 (JA, KO, SP) U

Kyung Yu, DDS #0312391370 S Beach Blvd Ste E 562-694-5850 F/T 1La Habra Smiles Dental #0291191250 W Whittier Blvd 562-266-9277 P/T 1 (SP, PE) U

LA JOLLAGrey Cunningham DDS-Prof Corp #0188147300 Girard Ave Ste 206 858-454-4114 F/T 1 P/T 1 U

Harmony Dental Group #0308284130 La Jolla Vlg Dr Ste 203 858-550-8000 P/T 1 (PE, SP) U

La Jolla Cosmetic/Fam #013483470 Nautilus St Ste 212 858-459-5591 P/T 1 (GE, RU, VI)


10 27

• Any service that is not specifically listed as a covered procedure.

• Dental expenses incurred in connection with any dental procedure started prior to the enrollee’s eligibility. Example: teeth prepared for crowns, root canals in progress, orthodontics.

• Congenital malformations.

• Dispensing of drugs not normally supplied in a dental office.

• Cases in which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained or where the prognosis is poor or guarded.

• Dental services received from any dental office other than the assigned dental office unless expressly authorized in writing by Delta Dental or as cited under “Emergency Services”.

• Prophylactic removal of impactions (asymptomatic nonpathological).

• “Consultations” for noncovered services.

• Implant placement or removal, appliances placed on, or services associated with, implants.

ORTHODONTIC LIMITATIONS AND EXCLUSIONS(PARTIAL LIST)

• Orthodontic treatment must be provided by a member of the orthodontic network.

• Program benefits cover 24 months of usual and customary orthodontic treatment.

• If your coverage is terminated for any reason, and you are receiving any orthodontic treatment at the time, your copayment shall be $2,300 for dependent children to age 19 (and $2,500 for covered adults and dependent adult children) and be prorated over the number of months to completion of the treatment. Terms and conditions are arranged between you and the orthodontist.

• A consultation fee may be charged if treatment is not required, or if you elect not to start treatment after a diagnosis and consultation have been completed.

• Pre-, mid- and post-treatment records (cephalometric x-rays, tracings, photographs and study models) are excluded.

• Retreatment of orthodontic cases is excluded.

• Lost, stolen or broken appliances are excluded.

• Orthodontic treatment in progress is limited to new DeltaCare USA enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.

When you enroll in DeltaCare USA, you select a participating dental office from the network directory to take care of dental needs for you and your family. After you have enrolled, you will receive an Evidence of Coverage booket that fully describes the benefits of your dental program, a welcome letter and a DeltaCare USA membership card. The welcome letter will have the address and telephone number of your participating network dentist. To receive all necessary dental care covered by the program, simply call your selected dental office to make an appointment.

Remember to always contact your network dentist. Dental services which are not performed by this dentist or are not authorized in advance by Delta Dental will not be covered under the DeltaCare USA program.

LIMITATIONS OF BENEFITS (PARTIAL LIST)

• Prophylaxis is limited to two treatments at no cost in any 12 consecutive months; additional treatments are available with a $27 patient copayment.

• Full upper and/or lower dentures are not to exceed one each in any five-year period.

• Replacement of partial dentures within any five-year period is not covered unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible.

• Denture relines are limited to one per denture during any 12 consecutive months.

• Periodontal treatments (root planing/subgingival curettage) are limited to five quadrants during any 12 consecutive months.

• Bitewing x-rays are limited to not more than one series of four films in any six-month period.

• Full mouth x-rays are limited to one set every 24 consecutive months.

• Sealants are limited to noncarious, nonrestored permanent first and second molars through age 15.

EXCLUSIONS (PARTIAL LIST)

The following services are not covered.

• General anesthesia and the services of a special anesthesiologist.

• Cosmetic dental care.

• Dental conditions arising out of and due to the enrollee’s employment or for which Workers’ Compensation is payable. Services which are provided to the enrollee by state government or agency thereof, or are provided without cost to the enrollee by any municipality, county or other subdivisions.

• Dental services performed in a hospital and related hospital fees.

• Loss or theft of fixed and removable prosthetics (crowns, bridges, full or partial dentures).

• Dental expenses incurred in connection with any dental procedure started after termination of eligibility of coverage.

CUDAHYCudahy True Smile Dentistry #0309648036 Atlantic Ave 323-562-4604 F/T 1 (VI) U

St James Dental Group #0251917607 Atlantic Ave 323-771-7254 F/T 2 (PE, SP)CULVER CITYAll Care Dental #0059524310 Overland Ave 310-837-8087 F/T 1 (PE)Culver City Family Dentistry #0135144909 Sepulveda Blvd 310-313-3100 F/T 1 (SP) U

Precision Dental Inc #0150625903 Sepulveda Blvd # B 310-390-3565 P/T 1 (Pe, Sp) U

Smile Dental #00027710920 Venice Blvd 310-204-6661 F/T 1 (SP, HR, TA)West View Dental #03092510814 Jefferson Blvd Ste G 310-204-0440 P/T 2 U

CYPRESSCa Dental Group of Cypress #00867411741 Valley View St Ste E 714-826-3000 P/T 1 (SP, VI) U

Cypress Dental Group #0153089922 Walker St Ste C 714-220-0354 F/T 1 (PE, TA, SP, HE) U

Cypress Plaza Dental Group #0272535460 Orange Ave 714-226-9630 P/T 2 (SP) U

Harish Hegde, DDS #0135319111 Valley View St Ste 106 714-995-1222 F/T 1 (SP) U

Katella Dental Center #3645016929 Katella Ave 714-952-3044 F/T 2 (VI)DANA POINTDana Point Dental Group #01900434080 Golden Lantern St 949-661-5664 P/T 2 (IT, PE, SP, TH) U

DEL MARDel Mar Professional Dtl Grp #00727213983 Mango Dr Ste 104 858-792-666 P/T 1 (SP, PE)DELANOLeticia Tolentino, DMD Inc #0138571625 Cecil Ave Ste A 661-725-9393 F/T 1 (SP, TA) U

DIAMOND BARDiamond Dental Care #3C4401303 S Diamond Bar Blvd # 2C 909-860-7579 P/T 2 (EI, SP, PE)Edward Mousally, DDS #36000123525 Golden Springs Dr # C 909-860-9399 F/T 1Grand Avenue Dentistry #1981011111 Grand Ave Ste G 909-396-7474 P/T 1 (SP)Wasseem Samaan, DDS #2C0601750 N Diamond Bar Blvd # 216 909-860-3111 F/T 2 P/T 1 (AR, SP) U

DOWNEYBaek Choung, DDS #0293238653 Florence Ave 562-622-0066 F/T 1 (KO, SP)Charles Stucken, DDS #3598018847 Imperial Hwy Ste C2 562-861-4011 F/T 1 (SP) U

Dental Pros #02362212156 Lakewood Blvd 562-803-1600 F/T 1 P/T 1 (SP, RU, VI) U

Downey Dental Center #2500018515 Florence Ave Ste 200 562-869-4532 F/T 1 P/T 3 (PE, SP) U

Downey Dental Group #0216858102 3Rd St 562-803-3333 F/T 2 (SP) U

Family Dental Center #03400110501 Lakewood Blvd Ste A 562-862-2341 F/T 3 P/T 1 (SP) U

Fred Bina, DDS #15260111849 Paramount Blvd 562-869-2596 F/T 3 (SP, PE)Kenneth W Cheng, DDS #0331138029 Imperial Hwy 562-862-6979 P/T 1 (CA, KO, SP) U

Planet Dental #0006468843 Rosecrans Ave Ste A 562-633-9300 F/T 2 (SP, PE) U

Quality Dentistry #0232998485 Florence Ave 562-869-2091 F/T 2 (PE, SP)Smilecare-Downey #0039559474 Firestone Blvd 562-803-4224 P/T 6 (SP) U

Soheir Azer, DDS #00275510800 Paramount Blvd Ste 307 562-923-3714 F/T 1 (AR)Ying Wu DDS., Inc #01260012651 Lakewood Blvd Ste 101 562-904-1150 F/T 1 (SP, CH)DUARTEBright Smile Family Dental #0018202233 Huntington Dr 626-359-9898 F/T 1 P/T 1 (SP) U

Duarte Family Dentistry #0841011217 Buena Vista St Ste 202 626-357-2254 P/T 1 (SP)EL CAJONAndrzej Lubczuk, DDS #029175707 Arnele Ave 619-444-1001 F/T 2 P/T 1 (SP)Cottonwood Dental Group #0134602451 Jamacha Rd Ste 104 619-444-0500 F/T 3Dr Korel Family Dentistry #3695011265 Avocado Ave Ste 102 619-444-3393 F/T 1 (AR)East County Dtl Associates #007821700 N Johnson Ave Ste P 619-444-3127 F/T 2 (AR, SP, VI)East County Family Dental Ctr #02143613465 Cam Canada Ste 110-A 619-390-3669 F/T 1 (SP, TA) U

El Cajon Family Dental #0292032720 Fletcher Pkwy 619-466-1292 F/T 1 (SP, AR)Horizon Dental Group #2C8201742 Broadway 619-440-0071 F/T 1 P/T 1 U

La Maestra Family Clinic Inc #024593183 S 1st St 619-328-1335 F/T 4 (SP, AR) U

Pacific Dental Grp- El Cajon #021723895 Jackman St 619-447-3100 U

Smilecare-El Cajon #0035081242 E Main St 619-444-6355 F/T 2 P/T 6 (SP)Smilecare-El Cajon II #0031542990 Jamacha Rd Ste 132 619-670-1700 F/T 2 P/T 5 (SP)Sun Valley Dental Care #0242481209 E Main St 619-442-0707 F/T 1 U

EL CENTROSouthwest Dental Group #0342501502 S La Brucherie Rd 760-482-5505 (SP)EL MONTEAlfonso Martinez, DDS #01285111733 Valley Blvd Ste A 626-575-7565 F/T 1 (SP)Central Dental Group #00378512072 Valley Blvd 626-527-2200 P/T 1 (CA, FR, JA, SP, TA, VI) U

David Kutner, DMD #0019013701 Santa Anita Ave 626-442-4582 P/T 1 (SP) U

Eastern Los Angeles Dental #00209612015 Garvey Ave Ste A 626-454-1888 F/T 1 (CH, SP) U

Family Dentistry #0028259060 Telstar Ave Ste 206 626-571-5975 F/T 1 (RO, HU, SP) U

Khan Dental Corporation #3596014900 Peck Rd 626-579-5158 F/T 2 (SP, HI) U

May Valley Dental Center #01926311766 Valley Blvd 626-448-5000 P/T 1 (SP) U

Mountain View Dental Group #0095574639 Peck Rd 626-444-9281 P/T 1 (SP, VI, CH)Select Dental Practice #0162303116 Peck Rd 626-454-2444 P/T 1 (SP, AM, FR, AR)

Shahriyar Behjou Dtl Corp #00171510755 Lower Azusa Rd Ste B 626-448-2040 F/T 2 P/T 1 (SP, TA, VI) U

Sunshine Dental Group #0195514161 Tyler Ave 626-579-4274 F/T 2 (CH, SP)Swe Dentistry #02041910354 Garvey Ave Ste B 626-350-8366 P/T 1 (SP) U

Tessie T Sy, DDS #0121064565 Peck Rd 626-350-3295 F/T 1 (CH, SP, TA)Victor Martin, DDS #0038243564 Santa Anita Ave Ste F 626-401-9808 F/T 1 (SP) U

ENCINITASCamino Dental Group #0146051340 Encinitas Blvd # 100 760-942-3900 P/T 2 (SP) U

ENCINOA One Dental Office #03379817175 Ventura Blvd 818-788-3488 F/T 1 (SP, TA) U

Dan Rosen, DDS #16460116542 Ventura Blvd Ste 505 818-907-6736 F/T 3 (HE, SP) U

Daniel Tebbi, DMD #03295616661 Ventura Blvd Ste 620 818-789-2034 F/T 1 U

Encino Cosmetic Dental Group #02386516133 Ventura Blvd Ste 1100 818-906-2222 F/T 1 (SP, PE) U

Encino Dental Center #18440117815 Ventura Blvd Ste 101 818-708-1200 F/T 1 (HE, SP)Encino Dental Esthetics #01996117525 Ventura Blvd Ste 100 818-784-7832 F/T 1 (SP, PE) U

Encino Family Dental Group #23750115720 Ventura Blvd Ste 322 818-788-7060 F/T 2 (FR, HE, TA) U

Encino Smile Center Inc #01824515720 Ventura Blvd Ste 300 818-788-6684 P/T 1 (AM, AR, RU, TA) U

Iraj Ebrami, DDS #00286116311 Ventura Blvd Ste 640 818-905-8337 P/T 1 (HE, PE) U

Moshe Abramovici, DDS #01761916550 Ventura Blvd Ste 403 818-986-0898 P/T 1 (HE, RO) U

Rene Ghotanian, DDS #1799015363 Balboa Blvd Ste 346 818-990-3551 F/T 1 (Sp)ESCONDIDOAcacia Dental Care #003541639 S Escondido Blvd 760-489-6197 P/T 2 (SP)El Norte Family Dental #154801306 W El Norte Pkwy Ste D E 760-480-5600 P/T 1 (SP)Escondido Dental Group #007041403 W Felicita Ave 760-233-2260 P/T 1Family Care Dental #1918011114 W Valley Pkwy 760-738-1070 F/T 1 P/T 1 (Sp, Ta, Vi)Gentle Dental-Del Lago #0051323440 Del Lago Blvd Ste C 760-746-8777 F/T 2 P/T 1Shahriyar Zandkarimi, DDS #005335240 W Mission Ave Ste A B 760-747-7000 F/T 1Village Dental Center #1969018895 Lawrence Welk Dr 760-749-7500 F/T 1FONTANABright Now! Dental #01795216135 Sierra Lakes Pkwy 909-356-2006 F/T 8 P/T 18 (KO, SP) U

Dr Voras Gateway Dtl Ofc #00766115032 Summit Ave Ste 410 909-899-3940 F/T 1Fontana Dental Group #1513019193 Sierra Ave Ste D 909-822-2226 F/T 3 (PL, SP, TA)Gupta Dental Group #32520111623 Cherry Ave Ste B2 909-355-1485 F/T 1 P/T 1 (SP, HI)Gupta’s Dental Office #03062116049 Baseline Ave Unit 3 909-356-9752 F/T 2 U

Heritage Dental Care #3C29017360 Cherry Ave Ste 340 909-355-9350 F/T 1 P/T 1 (SP, HI) U

Laura Jimenez, DDS #02831517500 Foothill Blvd Ste C2 909-357-7000 F/T 1 (SP) U

Morningside Dental Group #01601414584 Baseline Ave Ste 340 909-822-7374 F/T 1 (HI, SP, PE) U

Narendra Vyas, DDS., Inc #3686019647 Sierra Ave 909-823-5959 F/T 1 (SP, HI) U

Sahara Dental #01355417250 Foothill Blvd Ste E 909-428-8500 P/T 1 (AR, SP)Sierra Family Dentistry #0168929870 Sierra Ave Ste B 909-823-2020 P/T 1 (SP, HI, AR)Sierra Lakes Dental Group #02105616475 Sierra Lakes Pkwy 909-357-0869 P/T 2 (VI, SP) U

Sierra Pkwy Dental Care #03353216953 Sierra Lakes Pkwy #110 909-357-3900 P/T 1 (HI, SP) U

Triangle Dental Group #01411614305 Baseline Ave 909-355-1700 F/T 1 P/T 1 (SP) U

Vahan Grigoryan, DDS #0156127993 Sierra Ave Ste H 909-428-5111 F/T 1 (SP, KO) U

Viven Maghiran, DDS #02836914755 Foothill Blvd Ste E 909-349-1360 F/T 1 U

FOOTHILL RANCHTowne Centre Dental Group #01942145 Auto Center Dr Ste 110 949-588-5906 P/T 2 (HI, PE, SP, TA) U

FOUNTAIN VALLEYDavid Cohen, DDS #00251611180 Warner Ave Ste 451 714-444-4428 F/T 1 (SP) U

Fountain Valley Dental Esth #01683617900 Brookhurst St Ste A 714-887-4337 F/T 1 P/T 1 (KO, SP) U

Quality Dental Care #38420117150 Euclid St Ste 311 714-444-4224 F/T 1 (AR, RU, SP) U

Wadid Fattouch, DDS 186301 11180 Warner Ave Ste 251 714-557-8492 F/T 1 (AR, FR, PE, SP, VI) U

FULLERTONA Dentistry #014793536 W Commonwealth Ave Ste A 714-449-1686 P/T 1 (SP) U

Alice Skuben, DDS #364101170 N Raymond Ave 714-870-2000 F/T 2 (CS, SP) U

Amit Shah, DDS #010880137 W Chapman Ave Ste A 714-738-6001 F/T 1Brite Dental Group #0131741573 S Harbor Blvd 714-224-5255 P/T 1 (PE, SP) U

Eric Meyer, DDS #2760012720 N Harbor Blvd Ste 110 714-879-7943 P/T 1Fullerton Dental Center #010101446 E Commonwealth Ave 714-680-6767 F/T 1 P/T 1 (KO, SP) U

Fullerton Family Dental #033363906 W Orangethorpe Ave 714-871-3900 F/T 1 (CH, SP, TA)James Chou, DDS #0333642949 Brea Blvd 714-710-0300 F/T 1 P/T 1 (SP, VI)Jane Skuben, DDS #0137881690 N Placentia Ave 714-528-0600 P/T 1 (SP, CH, TA) U

Newport Dental #0039891718 W Orangethorpe Ave 714-525-3855 F/T 5 P/T 11 (SP)Nilar Thein, DDS #017507717 N Placentia Ave 714-577-0105 P/T 2 (SP)Real Dentistry #026775100 Laguna Rd Ste 202 714-525-2888 F/T 1 (SP, TA, VI)Sayed Fazey, DDS #0328801105 S Euclid St Ste E 714-738-0304 F/T 1 U

Sunshine Dental #015258506 W Commonwealth Ave 714-738-7777 F/T 1 (SP)Us Dental #0047161019 N Harbor Blvd 714-992-0300 F/T 1 (PE, SP) U

Valencia Family Dental Care #015610345 S Euclid St Ste A 714-773-9300 F/T 1 P/T 1 (HI, SP) U

GARDEN GROVEBrentwood Dental #02286012400 Euclid St 714-537-1600 F/T 1 (VI) U

Brookhurst Dental Group #03112612132 Brookhurst St 714-638-7111 P/T 1 (SP, HI) U

Century Dental Care #01170113011 Century Blvd 714-534-7020 F/T 1 (KO, SP) U

Coastal Dental Care #00788010044 Westminster Ave 714-539-7070 F/T 3 P/T 1 (KO, SP)Garden Grove Dental #00883312630 Brookhurst St Ste B 714-530-4920 F/T 3 P/T 1 (FR, SP, TA, HU, CS, RU, VI) U

Leaders Dental Group #02152813031 Kerry St 714-530-9901 P/T 1Mass Dental #0327729520 Garden Grove Blvd # 14 714-537-9160 P/T 1Primary Dental Care #00029712570 Brookhurst St Ste 2 714-537-5700 F/T 1 (RU, SP) U

Universal Care Dental #12740112511 Brookhurst St 714-530-9801 F/T 3 (SP, VI) U

GARDENAAll Friends Dental Center 028370 1600 W Redon Bh Blvd Ste 203 310-808-0198 F/T 1 P/T 1 (CA, SP)City Dental Center #0018131300 W 155th St Ste 208 310-715-2723 P/T 1 U

Dr Ly Vina Dental Group #02932815422 Crenshaw Blvd 310-352-4939 P/T 1 (VI) U

Harry Kim, DDS #01923415400 Crenshaw Blvd 310-516-9858 F/T 1 (SP, KO)Plaza Dental #17330114240 S Vermont Ave 310-515-5511 F/T 2 (SP) U

GLENDALEAlenoush Bagdasaryan, DDS #001666457 Palm Dr Ste 100 818-956-3733 F/T 2 (AM, SP, PE, RU)Artemis Saradjian, DDS #003132205 S Verdugo Rd Ste A 818-244-4949 F/T 3 (AM, PE, RU, SP)Broadway Dental Office #162301727 E Broadway 818-240-5888 F/T 1 (Sp) U

Carmen Ohanian, DDS #012933607 N Central Ave Ste 301 818-244-0215 F/T 1 (AM, PE, RU) U

Central Dental Care #0018171110 N Brand Blvd Ste 202 818-242-4781 P/T 1 (AM, PE, SP)Cyberdent #0110816300 San Fernando Rd 818-547-4455 F/T 1 (AM, RU)Daniel Estacio, DDS #0137391140 E Chevy Chase Dr 818-247-3387 F/T 1 P/T 1 (SP, TA) U

Dental Care Studios #0299151141 N Brand Blvd Ste 500 818-240-3700 F/T 1 (AM, PE, RU, FR) U

Dental Central Group #027579814 E Broadway Ste 4 818-241-1160 P/T 1 (SP, AM) U

Fmly Dtl Health Dr Ligaya #028264125 E Glenoaks Blvd Ste 107 818-484-8508 F/T 1Glendale Premier Dtl Center #023481819 N Pacific Ave 818-240-1760 F/T 1 P/T 1 (SP, AM, GE, FR)Hamlet Davari, DDS #1883011110 N Brand Blvd Ste 202 818-782-8120 P/T 1 (AM, PE, SP)


1126

D0100-D0999 DIAGNOSTICD0120 Periodic oral evaluation — established patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0140 Limited oral evaluation — problem focused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0145 Oral evaluation for a patient under three years of age and counseling with

primary caregiver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0150 Comprehensive oral evaluation — new or established patient . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0160 Detailed and extensive oral evaluation — problem focused, by report . . . . . . . . . . . . . . . . . . . No CostD0170 Re-evaluation — limited, problem focused (established patient; not post-operative visit) . . . No CostD0180 Comprehensive periodontal evaluation — new or established patient . . . . . . . . . . . . . . . . . . . No CostD0210 Intraoral radiographs — complete series (including bitewings) — limited to 1 series every 24 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0220 Intraoral — periapical first film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0230 Intraoral — periapical each additional film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0240 Intraoral — occlusal film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0270 Bitewing radiograph — single film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0272 Bitewings radiographs — two films. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0273 Bitewings radiographs — three films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0274 Bitewings radiographs — four films — limited to 1 series every 6 months . . . . . . . . . . . . . . . No CostD0330 Panoramic film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0460 Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0470 Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0472 Accession of tissue, gross examination, preparation and transmission of written report . . . . . No CostD0473 Accession of tissue, gross and microscopic examination, preparation and transmission of

written report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0474 Accession of tissue, gross and microscopic examination, including assessment of surgical

margins for presence of disease, preparation and transmission of written report . . . . . . . . . . . No CostD0999 Unspecified diagnostic procedure, by report — includes office visit, per visit (in addition

to other services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10.00

D1000-D1999 II. PREVENTIVED1110 Prophylaxis cleaning — adult — 2 per 12 month period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD1110 Additional prophylaxis cleaning — adult (within the 6 month period) . . . . . . . . . . . . . . . . . . . . $27.00D1120 Prophylaxis cleaning — child — 2 per 12 month period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD1120 Additional prophylaxis cleaning — child (within the 6 month period) . . . . . . . . . . . . . . . . . . . . $27.00D1203 Topical application of fluoride — child — to age 19; 2 per 12 month period . . . . . . . . . . . . . . No CostD1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk

patients — child to age 19; 2 per 12 month period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD1330 Oral hygiene instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD1351 Sealant — per tooth — limited to permanent molars through age 15 . . . . . . . . . . . . . . . . . . . $15.00D1352 Preventive resin restoration — per tooth — limited to permanent molars through age 15 . . . $15.00D1510 Space maintainer — fixed — unilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $65.00D1515 Space maintainer — fixed — bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $65.00D1520 Space maintainer — removable — unilateral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $65.00D1525 Space maintainer — removable — bilateral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $65.00D1550 Re-cementation of space maintainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D1555 Removal of fixed space maintainer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00

D2000-D2999 III. RESTORATIVEIncludes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures.D2140 Amalgam — one surface, primary or permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $27.00D2150 Amalgam — two surfaces, primary or permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $32.00D2160 Amalgam — three surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $37.00D2161 Amalgam — four or more surfaces, primary or permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D2330 Resin-based composite — one surface, anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00D2331 Resin-based composite — two surfaces, anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $80.00D2332 Resin-based composite — three surfaces, anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $80.00D2335 Resin-based composite — four or more surfaces or involving incisal angle (anterior) . . . . . . . $80.00D2390 Resin-based composite crown, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D2391 Resin-based composite — one surface, posterior 1, 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2392 Resin-based composite — two surfaces, posterior 1, 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2393 Resin-based composite — three surfaces, posterior 1, 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2394 Resin-based composite — four or more surfaces, posterior 1, 2 . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2510 Inlay — metallic — one surface 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2520 Inlay — metallic — two surfaces 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2530 Inlay — metallic — three or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2542 Onlay — metallic — two surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2543 Onlay — metallic — three surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2544 Onlay — metallic — four or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2610 Inlay — porcelain/ceramic — one surface 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2620 Inlay — porcelain/ceramic — two surfaces 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2630 Inlay — porcelain/ceramic — three or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2642 Onlay — porcelain/ceramic — two surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2643 Onlay — porcelain/ceramic — three surfaces 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2644 Onlay — porcelain/ceramic — four or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2650 Inlay — resin-based composite — one surface 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2651 Inlay — resin-based composite — two surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2652 Inlay — resin-based composite — three or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2662 Onlay — resin-based composite — two surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2663 Onlay — resin-based composite — three surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2664 Onlay — resin-based composite — four or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2710 Crown — resin-based composite (indirect) 3, 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $125.00D2712 Crown — ¾ resin-based composite (indirect) 3, 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $125.00D2720 Crown — resin with high noble metal 3, 4, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D2721 Crown — resin with predominantly base metal 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D2722 Crown — resin with noble metal 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D2740 Crown — porcelain/ceramic substrate 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00

D2750 Crown — porcelain fused to high noble metal 3, 4, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D2751 Crown — porcelain fused to predominantly base metal 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D2752 Crown — porcelain fused to noble metal 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D2780 Crown — ¾ cast high noble metal 3, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2781 Crown — ¾ cast predominantly base metal 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2782 Crown — ¾ cast noble metal 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2790 Crown — full cast high noble metal 3, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2791 Crown — full cast predominantly base metal 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2792 Crown — full cast noble metal 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2794 Crown — titanium 3, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D2910 Recement inlay, onlay or partial coverage restoration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D2915 Recement cast or prefabricated post and core. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D2920 Recement crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D2930 Prefabricated stainless steel crown — primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D2931 Prefabricated stainless steel crown — permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D2932 Prefabricated resin crown — anterior primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D2933 Prefabricated stainless steel crown with resin window — anterior primary tooth . . . . . . . . . . $60.00D2940 Protective restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15.00D2950 Core buildup, including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00D2951 Pin retention — per tooth, in addition to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00D2952 Post and core in addition to crown, indirectly fabricated — includes canal preparation 5 . . . . $90.00D2953 Each additional indirectly fabricated post — same tooth — includes canal preparation 5 . . . . $90.00D2954 Prefabricated post and core in addition to crown — base metal post; includes canal

preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D2957 Each additional prefabricated post — same tooth — base metal post; includes canal

preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D2970 Temporary crown (fractured tooth) — palliative treatment only . . . . . . . . . . . . . . . . . . . . . . . . . No CostD2980 Crown repair, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00

D3000-D3999 IV. ENDODONTICSD3110 Pulp cap — direct (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $12.00D3120 Pulp cap — indirect (excluding final restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $12.00D3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to

the dentinocemental junction and application of medicament . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D3221 Pulpal debridement, primary and permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D3222 Partial pulpotomy for apexogenesis — permanent tooth with incomplete root development. . . . . . $45.00D3230 Pulpal therapy (resorbable filling) — anterior, primary tooth (excluding final restoration). . . . . $45.00D3240 Pulpal therapy (resorbable filling) — posterior, primary tooth (excluding final

restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D3310 Root canal — endodontic therapy, anterior tooth (excluding final restoration) 6 . . . . . . . . . . . . $150.00D3320 Root canal — endodontic therapy, bicuspid tooth (excluding final restoration) 6 . . . . . . . . . . . . $200.00D3330 Root canal — endodontic therapy, molar (excluding final restoration) 6 . . . . . . . . . . . . . . . . . . . $250.00D3346 Retreatment of previous root canal therapy — anterior 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D3347 Retreatment of previous root canal therapy — bicuspid 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D3348 Retreatment of previous root canal therapy — molar 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300.00D3351 Apexification/recalcification — initial visit (apical closure/calcific repair of

perforations, root resorption, etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D3410 Apicoectomy/periradicular surgery — anterior 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D3421 Apicoectomy/periradicular surgery — bicuspid (first root) 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D3425 Apicoectomy/periradicular surgery — molar (first root) 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D3426 Apicoectomy/periradicular surgery (each additional root) 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D3430 Retrograde filling — per root 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D3450 Root amputation, per root — not covered in conjunction with a hemisection 6. . . . . . . . . . . . . $50.00

D4000-D4999 V. PERIODONTICSIncludes preoperative and postoperative evaluations and treatment under a local anesthetic.D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or tooth bounded

spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D4211 Gingivectomy or gingivoplasty — one to three contiguous teeth or tooth bounded

spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D4240 Gingival flap procedure, including root planing — four or more contiguous teeth or

tooth bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D4241 Gingival flap procedure, including root planing — one to three contiguous teeth or tooth

bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D4260 Osseous surgery (including flap entry and closure) — four or more contiguous teeth

or tooth bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400.00D4261 Osseous surgery (including flap entry and closure) — one to three contiguous teeth or

tooth bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400.00D4341 Periodontal scaling and root planing — four or more teeth per quadrant — limited to 5

quadrants during any 12 consecutive months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D4342 Periodontal scaling and root planing — one to three teeth per quadrant — limited to 5

quadrants during any 12 consecutive months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis — limited

to 1 treatment in any 12 consecutive months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15.00D4910 Periodontal maintenance — limited to 2 treatments each 12 month period . . . . . . . . . . . . . . . $15.00

D5000-D5899 VI. PROSTHODONTICS (removable)D5110 Complete denture — maxillary 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.00D5120 Complete denture — mandibular 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.00D5130 Immediate denture — maxillary 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $450.00D5140 Immediate denture — mandibular 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $450.00D5211 Maxillary partial denture — resin base (including any conventional clasps, rests and

teeth) 7, 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300.00D5212 Mandibular partial denture — resin base (including any conventional clasps, rests and

teeth) 7, 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300.00D5213 Maxillary partial denture — cast metal framework with resin denture bases (including

any conventional clasps, rests and teeth) 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $375.00

Schedule A Description of Benefits and CopaymentsThe benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2011 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.

Code Description Enrollee Pays Code Description Enrollee Pays

Rene Ghotanian, DDS #0C4301500 E Olive Ave Ste 250 818-846-2600 F/T 1 P/T 1 (SP, AM)San Gabriel Summit Dental #000082255 E Orange Grove Ave Ste B 818-557-0996 F/T 1 (SP, TA)Toluca Lake Dental #0129343808 W Riverside Dr Ste 408 818-842-4019 F/T 1 (AM, SP, TA, PE) U

Vigen Alikhanian, DDS #0220623927 W Burbank Blvd 818-845-0900 F/T 1 (SP, RU, AM)Vineland Dental Practice #01173910970 Sherman Way Ste 102 818-565-0001 F/T 1 (KO, SP) U

CALABASASCalabasas Dental Group #35650126500 Agoura Rd Ste 115 818-871-0680 F/T 1 (PE, SP) U

CALEXICOCalexico Family Dentistry #024280400 Mary Ave 760-357-6409 P/T 1 (SP) U

Calexico Family Dentistry #0242822300 N Imperial Ave Ste E 760-357-1632 P/T 2 (SP) U

CAMARILLOCamarillo Dental Group #1987012380 Las Posas Rd Ste A D 805-388-9110 F/T 1 P/T 1 (SP) U

Douglas R Dill, DDS #0288992107 Pickwick Dr 805-445-1333 F/T 1 (SP) U

Farid Sehati, DDS #285401484 Mobil Ave Ste 33 805-482-9568 F/T 1 (PE, SP) U

Las Posas Dental Care #0031183901 Las Posas Rd Ste 209 805-383-6745 F/T 1 (CH, SP)Mission Oaks Dental Group #0172914900 Verdugo Way Ste A 805-484-7277 P/T 2 (SP) U

Palm Dental Care #0081852177 Ventura Blvd 805-388-1048 P/T 3 (JA, PE, SP, TA)R Trent/Gina Torgersen, DDS #018205484 Mobil Ave Ste 31 805-484-1221 F/T 2 (SP) U

Stars Dental Inc #0252221727 E Daily Dr Ste H 805-764-0222 F/T 1 (PE, SP) U

CANOGA PARKAllure Dental #0224178358 Topanga Canyon Blvd 818-348-8400 F/T 1 (AM, SP)Cosmeticare #02793721123 Victory Blvd 818-888-2700 P/T 1Kishore Shah, DDS #37540121001 13 Sherman Way 818-346-7032 P/T 2 (SP, TA) U

Marjan Garmestani, DDS #01724322030 Sherman Way Ste 317 818-610-2007 F/T 1 (PE, SP) U

Omega Dental Group #02557221712 Sherman Way 818-883-6634 F/T 1 (HE, PE, SP) U

Pary Afrashteh, DDS #3627017259 Owensmouth Ave 818-999-9900 F/T 1 (FR, SP, PE)Sheldon Springer, DDS #02316522030 Sherman Way Ste 204 818-716-5512 F/T 1 (SP) U

Sinai Dental Clinic #0028587257 Vassar Ave Ste 203 818-251-9794 F/T 1 (SP, PE, TR)Valley Circle Family Dental #02147923727 Roscoe Blvd 818-888-8824 P/T 1 (PE, TA) U

Warner Dental Care #02507121632 Sherman Way 818-999-6979 F/T 1West Valley Dental #2C48016543 Topanga Canyon Blvd 818-883-7979 P/T 1 (SP)White Smile Dental Group #00362422030 Sherman Way Ste 202 818-887-0260 P/T 2 (SP, PE, TA) U

CANYON COUNTRYAnna Liberman, DDS #14660118507 Soledad Canyon Rd 661-252-0020 F/T 2 (RU, SP)

Smiles Dental Group #03124018520 Soledad Canyon Rd 661-252-2800 P/T 1 (AM, RU, SP) U

CARLSBADCarlsbad Forum Dental #0269311905 Calle Barcelona Ste 229 760-479-0971 P/T 1 (AR) U

Carlsbad Open 7 Days Dental #0C88015814 Van Allen Way Ste 220 760-918-9000 F/T 1 (SP)Gateway Dental Group #0295162635 Gateway Rd Ste 101 760-431-8112 P/T 2 (SP) U

Gentle Dental Carlsbad #0300352620 El Camino Real Ste A 760-720-0966 F/T 2 P/T 1 (TA) U

Plaza Family Dental #0219182630 El Camino Real 760-434-1761 P/T 1 (SP) U

CARSONA1 Care Dental Center #023873602 W Sepulveda Blvd 310-830-3338 P/T 1 (SP, KO) U

Care Dental Center #01459523517 Main St Ste 106 310-513-0222 P/T 2 (SP, PE) U

Carson Dental Care #022146240 W Carson St 310-549-5580 F/T 1 P/T 1 (SP, TA)Family Dental Center #36370122813 Figueroa St 310-549-3717 F/T 1 (AR, SP)Great Choice Community Dental #032945247 W Carson St 310-847-7077 P/T 1 U

Hyacinth Ezeani, DDS #01486120763 Avalon Blvd 310-719-1865 P/T 1 (Sp) U

Island Dental #016934301 W Carson St 310-787-7053 F/T 1 (SP)Jaubin Nguyen, DDS #0123431754 E Carson St 310-518-7068 F/T 1 (SP, VI)Judina Morales, DDS #02465820401 Avalon Blvd Ste A 310-217-1507 F/T 1 (SP)Leticia Tolentino, DMD Inc #013256860 E Carson St Ste 106 310-522-9769 F/T 2 P/T 1 (TA) U

Randolph Lum, DDS #00254521847 Avalon Blvd 310-549-9710 F/T 1 (SP) U

Smilecare-Del Amo #003953550 E Del Amo Blvd 310-515-5672 P/T 3 U

CASTAICCastaic Dental Center #38540131886 Castaic Rd 661-257-2300 F/T 1 P/T 1 (CH, JA, AM, SP) U

Enitan Ibrahim, DDS #02712927947 Sloan Canyon Rd 661-294-3700 F/T 1Hasley Canyon Dental Group #01235629655 The Old Rd 661-702-8338 P/T 1 (PE, SP) U

CATHEDRAL CITYGentry Plaza Dental Care #1C350168555 Ramon Rd Ste D102 760-202-1171 F/T 1 (SP)Palm Dentistry #02962268487 E Palm Canyon Dr Ste 1 760-328-6208 F/T 2 (SP, TA) U

CerritosBloomfield Dental Center #18430112657 166th St 562-926-6502 F/T 1 (AR, SP) U

Cerritos Dental Center #03367111135 183Rd St 562-804-2296 P/T 1 (SP, TA) U

Cerritos Towne Ctr Dentistry #03309617550 Bloomfield Ave Ste C 562-809-4464 P/T 2 (CH, KO, SP) U

Eastern Dental Family Care #00561111466 South St 562-402-8166 F/T 1 (KO, SP, TA) U

Paul Kim, DMD #01321011900 South St Ste 122 562-809-6177 F/T 2 (SP, KO) U

CHATSWORTHDevonshire Plaza Dental Group #28410110230 Canoga Ave 818-341-8400 F/T 1Future Dental Care #02786410242 Canoga Ave 818-882-5252 P/T 1 (SP)Genuine Dental Care #01380410233 Topanga Canyon Blvd 818-772-5187 P/T 1 U

CHINOAnthony Kavorinos, DDS #03170112604 Central Ave 909-591-1745 F/T 1 P/T 1Brandon Chiu, DDS #02210813768 Roswell Ave Ste 211 909-590-8255 F/T 1 P/T 1Bright Smile Dental Care #01655412345 Mountain Ave Ste O 909-364-1330 F/T 1 (HI, SP) U

Chino Smiles Dental Group #0268526961 Schaefer Ave 909-590-0640 P/T 2 (SP) U

Family Dental Center #3676015436 Riverside Dr 909-465-5551 F/T 1 (SP)Galvan Family Dentistry Inc #0023374514 Philadelphia St Ste A 909-465-1016 P/T 1 (SP, TA) U

Group Dental Center Inc #0130235480 Philadelphia St Ste D 909-464-2399 F/T 1 (CH, SP)Smilecare-Chino #00396812233 Central Ave 909-628-0208 F/T 4 P/T 7 (SP) U

Upland Dental and Ortho #01459614335 Pipeline Ave Ste A 909-902-0800 P/T 2 (SP, CH, CA) U

William Valdez, DDS #3274014129 Riverside Dr 909-591-9211 F/T 1 (SP) U

CHINO HILLSChino Hills Dental Group #0031173410 Grand Ave Ste F 909-364-0001 F/T 2 P/T 1 (SP) U

Chino Hills Dental Office #0047652983 Chino Ave Ste A5 909-628-7000 F/T 1 (KO, SP)Dental Care Of Chino Hills #0318293280 Chino Hills Pkwy Ste 4 909-606-9907 P/T 1 (HI, SP, TA) U

Dentistry By Dr Doshi & Assoc #0195162140 Grand Ave Ste 265 909-364-9600 P/T 1 (HI) U

Pine Center Dental Group #0291765771 Pine Ave Ste S 909-597-2477 F/T 3 (SP, PE)Smile Savvy Dental Care #00567414676 Pipeline Ave Ste Q 909-393-3180 F/T 1 (TA, SP, KO, VI, TH)Tina Cho, DMD #02928014270 Chino Hills Pkwy 909-590-2229 P/T 1 (SP, KO)CHULA VISTABonita Smiles Dentistry #0182041558 E H St Ste B 619-421-9070 F/T 2 (FR, PE, SP) U

California Smiles #024548215 3rd Ave 619-427-7070 F/T 3 (SP, VI)Carmen Denise Maroon Lopez, DDS #0304172648 Main St Ste A 619-423-5200 F/T 1 (SP, TA) U

Dental Check Up #0120431010 Broadway Ste 5 619-422-0800 P/T 1 (SP)Gentle Dental Chula Vista #0C1801345 F St Ste 140 619-476-1001 F/T 1 P/T 2 (TA)Gentle Dental Chula Vista #003157301 3rd Ave 619-476-1444 F/T 1 P/T 1 (HI, SP)Maria Luisa Vales, DMD #00610388 E Bonita Rd Ste F 619-427-2646 F/T 1 (TA)Maria Zuniga, DDS Inc #011788985 Broadway Ste E 619-422-3473 F/T 1 (SP)Meigs Family Dental #0267761040 Tierra Del Rey Ste 209 619-656-9713 F/T 1 (SP)

Otay Lakes Dental Care #018811945 Otay Lakes Rd Ste H 619-397-5888 F/T 1 (TA) U

Palomar Dental Group #008781664 Palomar St Ste 1103 619-429-3948 F/T 1 P/T 1 (SP, VI)Perfecta Dental Group #012721314 Palomar St 619-498-3888 F/T 2 (CH, SP, VI)Smile Design Center #017111232 3rd Ave 619-827-0770 P/T 1 (SP, TA) U

Smile San Diego #031635585 Telegraph Canyon Rd 619-421-7010 F/T 3 P/T 1Smilecare-Chula Vista #004078510 Broadway Ste 4 5 619-476-9400 F/T 3 P/T 2 (SP) U

So. Bay Chula Vista Fam Dtl #005736290 Landis Ave Ste A B 619-691-0121 P/T 2 (SP, TA)Twin Oaks Family Dentistry #009447230 F St Ste D 619-427-5262 F/T 1 (FR, PE, SP, GE, TA)Village Dental Group #021040878 Eastlake Pkwy Ste 1511 619-739-4936 F/T 1 P/T 1 (SP) U

CITY OF INDUSTRYWalnut Smiles #02560521750 Valley Blvd Ste C 909-595-0807 P/T 1 U

CLAREMONTNewport Dental #012593406 Auto Center Dr 909-624-6199 F/T 7 P/T 12 (CH, SP)COLTONColton Dental Group #033235251 E Valley Blvd 909-825-0545 P/T 1 (HI, SP) U

Dental Associates of Colton #3492011080 E Washington St Ste B 909-783-9099 F/T 1 P/T 1 (SP, CH) U

St Patrick Dental Clinic #3685011200 E Washington St Ste F2 909-422-0885 P/T 2 (SP, TA) U

COMPTONLinda Onyeador, DDS #025979555 W Compton Blvd Ste 103 310-762-9292 F/T 1Sang Cho, DDS #002787402 S Long Beach Blvd 310-637-6187 F/T 1 (KO, SP, TA)CORONABright Now Dental #01178712636 Limonite Ave Ste 1A 951-808-4323 F/T 5 P/T 22 (SP, TA) U

Bright Now! Dental #010322140 W Ontario Ave Ste 105 951-735-4969 F/T 5 P/T 22 (SP) U

Canyon Dental #0238071561 E Ontario Ave Ste 103A 951-273-0555 F/T 1 (SP, HI) U

Corona Dental #029920161 N Mckinley St Ste 102 951-737-3746 F/T 1 P/T 1 (KO, SP) U

Corona Family Dental Group #0243041358 W 6th St # 101 951-734-4620 F/T 1 P/T 4 (SP, AR, FR) U

Corona Family Dentistry #0245413848 N Mckinley St Ste D 951-371-2424 F/T 1 (TA, SP)Dental Associates of Corona #0091951380 El Sobrante Rd 951-273-9580 F/T 2 (SP, TA, TH) U

Dental Health Corona #0271144264 Green River Rd 951-340-0200 F/T 3Dental R Us #0025421303 W 6th St Ste 103 951-898-2101 F/T 2Gentle Dental Corona #0329801074 W 6th St Ste 104 951-279-7650 P/T 4Hamner Square Dental #0228646987 Hamner Ave Ste 5 951-371-3464 P/T 1 (SP, VI) U

Harpreet Gill, DDS #000224360 W Foothill Pkwy 951-279-1172 F/T 1Joseph Rajabi, DDS #001604900 S Main St Ste 107 951-734-4170 P/T 1 (SP) U

Lita Hermansjah, DDS #015150916 W 6th St 951-738-1749 F/T 1 (SP, IN)Main Street Dental Group #013104131 W Ontario Ave Ste 102 951-898-9700 P/T 1 (SP) U

Mckinley Dental #011789115 N Mckinley St Ste 105 951-280-9300 F/T 1 (SP)Orchard Dental Group #0215352150 California Ave Ste 107 951-279-4333 P/T 1 (SP) U

Smile Now Dental Group #0228401760 W 6th St Ste 101 951-735-7300 F/T 1 (SP, TA, HI, CH, VI) U

Soft Care Dental #029917910 Washburn Ave Ste D 951-734-7717 P/T 1Soft Touch Dental #0106331411 Rimpau Ave Ste 106 951-280-0322 P/T 1 (SP, HI, TA)South Corona Dental Group #0042241312 E Ontario Ave Ste 102 951-273-0370 P/T 1 (SP) U

Sycamore Creek Dental #03024711882 De Palma Rd Ste E 2 951-277-7678 F/T 1CORONA DEL MARCorona Del Mar Dental Group #0292872345 E Coast Hwy Ste C 949-675-3131 P/T 1 U

COSTA MESAAdvan Dental Care #0126981503 S Coast Dr Ste 201 714-540-8547 P/T 2 (CH, SP) U

Bay Mesa Dental Office #0327702023 Harbor Blvd Ste D 949-646-9000 P/T 1 (SP, VI)Bright Dental Care #013279320 Bristol St Ste H 714-546-7595 F/T 2 (SP, PE) U

Bright Now! Dental Costa Mesa #0335812300 Harbor Blve Ste H-5 949-610-0146 P/T 9 (AR, SP)Dazzling Smile Dental Group #006360204 E 17th St Ste 201 949-515-8181 F/T 1 (AR, SP, HU) U

Fashion Dental #033267145 E 19th St Ste A 949-650-1414 F/T 1 U

Gentle Dental-Costa Mesa #0301012000 Harbor Blvd Ste B100 949-645-5070 F/T 3 P/T 3 (CH, PE, SP, TA, TR) U

Mehri Safari, DDS #0170462969 Harbor Blvd 714-424-9393 F/T 1 (SP, PE)Mesa Dental Center #196301267 E 17th St 949-646-2411 F/T 2 (AR, SP, HI, TH)Newport Dental Group #0221561835 Newport Blvd Ste E267 949-574-0100 P/T 1 (SP, PL, PE) U

Pacific Harbor Dental Group #0131683030 Harbor Blvd Ste G1 714-546-6100 P/T 1 (SP) U

So Cal Smiles Dentistry #029184230 E 17th St Ste 208 949-645-0045 P/T 1 (AR, TA, RU, SP) U

COVINAAhmed Saeed, DDS., Inc #015597661 S 2nd Ave 626-966-3571 P/T 1 (PE, SP)Arrow Smile Dental Clinic #02366820530 E Arrow Hwy 626-938-1236 F/T 1 (TA) U

College St Family Dtl Grp #032182153 W College St At 626-339-9085 P/T 1 (KO, SP)Covina Dental Office #0C59011052 N Citrus Ave 626-967-6767 F/T 1 P/T 1 (AR, PE, SP, VI) U

Dental Group of Covina #0007691406 N Azusa Ave Ste C 626-858-9940 P/T 1 (CH, SP) U

Patricia Lopez, DDS., Inc #023360675 S 2nd Ave 626-938-0195 F/T 1 (SP)Rubin Nichols, DDS., Inc #025177558 W Badillo St 626-331-0506 F/T 1 P/T 1


12 25


D5214 Mandibular partial denture — cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 7, 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $375.00

D5281 Removable unilateral partial denture — one piece cast metal (including clasps and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00

D5410 Adjust complete denture — maxillary 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5411 Adjust complete denture — mandibular 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5421 Adjust partial denture — maxillary 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5422 Adjust partial denture — mandibular 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5510 Repair broken complete denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D5520 Replace missing or broken teeth — complete denture (each tooth). . . . . . . . . . . . . . . . . . . . . . $15.00D5610 Repair resin denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5620 Repair cast framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D5630 Repair or replace broken clasp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5640 Replace broken teeth — per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15.00D5650 Add tooth to existing partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15.00D5660 Add clasp to existing partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5710 Rebase complete maxillary denture 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5711 Rebase complete mandibular denture 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5720 Rebase maxillary partial denture 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5721 Rebase mandibular partial denture 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5730 Reline complete maxillary denture (chairside) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5731 Reline complete mandibular denture (chairside) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5740 Reline maxillary partial denture (chairside) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5741 Reline mandibular partial denture (chairside) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5750 Reline complete maxillary denture (laboratory) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5751 Reline complete mandibular denture (laboratory) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5760 Reline maxillary partial denture (laboratory) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5761 Reline mandibular partial denture (laboratory) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5820 Interim partial denture (maxillary) — limited to initial placement of interim partial

denture/stayplate to replace extracted anterior teeth during healing 7 . . . . . . . . . . . . . . . . . . . $180.00D5821 Interim partial denture (mandibular) — limited to initial placement of interim partial

denture/stayplate to replace extracted anterior teeth during healing 7 . . . . . . . . . . . . . . . . . . . $180.00D5850 Tissue conditioning, maxillary 7, 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30.00D5851 Tissue conditioning, mandibular 7, 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30.00

D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS — Not Covered

D6000-D6199 VIII. IMPLANT SERVICES — Not Covered

D6200-D6999 IX PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge])

D6210 Pontic — cast high noble metal 5, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6211 Pontic — cast predominantly base metal 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6212 Pontic — cast noble metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6240 Pontic — porcelain fused to high noble metal 4, 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6241 Pontic — porcelain fused to predominantly base metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6242 Pontic — porcelain fused to noble metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6245 Pontic — porcelain/ceramic 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6250 Pontic — resin with high noble metal 4, 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6251 Pontic — resin with predominantly base metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6252 Pontic — resin with noble metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6545 Retainer — cast metal for resin bonded fixed prosthesis 4, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D6600 Inlay — porcelain/ceramic, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6601 Inlay — porcelain/ceramic, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6602 Inlay — cast high noble metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6603 Inlay — cast high noble metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6604 Inlay — cast predominantly base metal, two surfaces 2, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6605 Inlay — cast predominantly base metal, three or more surfaces 2, 10. . . . . . . . . . . . . . . . . . . . . OptionalD6606 Inlay — cast noble metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6607 Inlay — cast noble metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6608 Onlay — porcelain/ceramic, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6609 Onlay — porcelain/ceramic, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6610 Onlay — cast high noble metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6611 Onlay — cast high noble metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6612 Onlay — cast predominantly base metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6613 Onlay — cast predominantly base metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . OptionalD6614 Onlay — cast noble metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6615 Onlay — cast noble metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6720 Crown — resin with high noble metal 4, 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6721 Crown — resin with predominantly base metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6722 Crown — resin with noble metal 4, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6740 Crown — porcelain/ceramic 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6750 Crown — porcelain fused to high noble metal 4, 5, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6751 Crown — porcelain fused to predominantly base metal 4, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6752 Crown — porcelain fused to noble metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6780 Crown — ¾ cast high noble metal 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6781 Crown — ¾ cast predominantly base metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6782 Crown — ¾ cast noble metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6790 Crown — full cast high noble metal 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6791 Crown — full cast predominantly base metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6792 Crown — full cast noble metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6930 Recement fixed partial denture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D6940 Stress breaker 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated —

includes canal preparation 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $90.00D6972 Prefabricated post and core in addition to fixed partial denture retainer — base metal

post; includes canal preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D6973 Core buildup for retainer, including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00D6976 Each additional indirectly fabricated post — same tooth — includes canal

preparation 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $90.00D6977 Each additional prefabricated post — same tooth — base metal post; includes canal

preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D6980 Fixed partial denture repair, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00

D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERYIncludes preoperative and postoperative evaluations and treatment under a local anesthetic.D7111 Extraction, coronal remnants — deciduous tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $35.00D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) . . . . . . . . . . . . . . $35.00D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and

removal of bone and/or section of tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00

D7220 Removal of impacted tooth — soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00D7230 Removal of impacted tooth — partially bony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00D7240 Removal of impacted tooth — completely bony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D7241 Removal of impacted tooth — completely bony, with unusual surgical

complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D7250 Surgical removal of residual tooth roots (cutting procedure). . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00D7251 Coronectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D7286 Biopsy of oral tissue — soft — does not include histopathologic examination or other

pathology laboratory procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10.00D7310 Alveoloplasty in conjunction with extractions — four or more teeth or tooth spaces,

per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D7311 Alveoloplasty in conjunction with extractions — one to three teeth or tooth spaces,

per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D7320 Alveoloplasty not in conjunction with extractions — four or more teeth or tooth

spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00D7321 Alveoloplasty not in conjunction with extractions — one to three teeth or tooth

spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00D7471 Removal of lateral exostosis (maxilla or mandible) — per site. . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D7510 Incision and drainage of abscess — intraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D7960 Frenulectomy (frenectomy or frenotomy) — separate procedure . . . . . . . . . . . . . . . . . . . . . . . . $25.00

D8000-D8999 XI. ORTHODONTICSD8070 Comprehensive orthodontic treatment of the transitional dentition — child or

adolescent to age 19 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,600.00D8080 Comprehensive orthodontic treatment of the adolescent dentition — adolescent to

age 19 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,600.00D8090 Comprehensive orthodontic treatment of the adult dentition — adults, including

dependent adult children age 19 and older 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,800.00D8660 Pre-orthodontic treatment visit — not to be charged with any other consultation

procedure(s) 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD8680 Orthodontic retention (removal of appliances, construction and placement of

retainers) 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD8999 Unspecified orthodontic procedure, by report — includes the START-UP FEE, which

includes initial examination, diagnosis, consultation and initial banding . . . . . . . . . . . . . . . . . . $350.00

D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICESD9110 Palliative (emergency) treatment of dental pain — minor procedure . . . . . . . . . . . . . . . . . . . . . $35.00D9211 Regional block anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9212 Trigeminal division block anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9215 Local anesthesia in conjunction with surgery procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9310 Consultation — diagnostic service provided by dentist or physician other than

requesting dentist or physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9430 Office visit for observation (during regularly scheduled hours) — no other services

performed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9440 Office visit — after regularly scheduled hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00

Procedures not listed above are not covered, however, may be available at the Contract Dentist’s “filedfees.”

“Filed fees” means the Contract Dentist’s fees on file with Delta Dental. Questions regarding these feesshould be directed to Delta Dental’s Customer Service department at 800-422-4234.

FOOTNOTES1 An amalgam is the benefit.2 Optional is defined as any alternative procedure presented

by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the Limitations and Exclusions of the program. The applicable charge to the Enrollee is the difference between the Contract Dentist’s “filed fee” for the Optional procedure and the “filed fee” for the covered procedure, plus any applicable Copayment. “Filed fees” means the Contract Dentist’s fees on file with Delta Dental. Questions regarding the DeltaCare USA program should be directed to Delta Dental’s Customer Service department at 800-422-4234.

3 Replacement is subject to a limitation requiring the existing restoration to be 5+ years old.

4 Porcelain and other tooth-colored materials on molars are considered a material upgrade with a maximum additional charge to the Enrollee of $150.00.

5 Base or noble metal is the benefit. High noble metal (precious), if used, will be charged to the Enrollee at the additional maximum cost to the Enrollee of $100.00 per tooth. If an indirectly fabricated post and core is made of high noble metal, an additional fee up to $100.00 per tooth will be charged for the upgrade. This charge also applies to a titanium crown.

Dental Health Anaheim Hills #0251738295 E Monte Vista Rd Ste B 714-685-9197 P/T 2 (SP, HI, TA, KO, FR, GE, RU)Derrick Brown, DDS #021501853 N Harbor Blvd 714-535-2487 F/T 1Euclid Dental Center #0305511751 W Romneya Dr Ste D 714-772-3538 P/T 1 (SP, TA)Excel Dental #0214421602 N Lemon St 714-525-5558 F/T 1 (SP, VI, CH)Gentle Dental-Anaheim #0085352170 W Lincoln Ave 714-535-3933 F/T 1 P/T 1 (PE, RO, SP, VI) U

Grand Dental #0133373070 W Lincoln Ave Ste O 714-828-3028 F/T 1 (SP)Manhar Mistry DDSInc #1C7301420 S State College Blvd 714-772-0770 F/T 1 (SP)Maysoon Saeed, DDSInc #013160710 S Brookhurst St Ste K 714-758-0778 F/T 1 (AR, SP)Morgan Dental #0242342601 W Ball Rd Ste 101 714-995-4444 P/T 1Neeta Somani, DDSInc #0216901842 W Lincoln Ave Ste B 714-533-4321 F/T 1 (HI)Noemi Taguinod, Dental #026769408 S Beach Blvd Ste 113 714-816-0954 F/T 1 (SP, TA)Radiance Dental #0123895675 E La Palma Ave Ste 197 714-695-0593 P/T 1 (SP) U

Smile Select #3521018285 E Santa Ana Canyon Rd 714-974-5599 F/T 2 (SP)Smilecare-Anaheim #0022521112 N Magnolia Ave 714-828-1211 F/T 1 P/T 7 (SP)Smiles For Orange County #2350019672 Ball Rd 714-772-0102 F/T 1 (SP)State College Dental Group #003047330 N State College Blvd 105 714-772-5005 P/T 4 (SP, VI) U

Sunkist Dental Office #0140972500 E Ball Rd Ste 150 714-533-9670 P/T 1 (SP, HI) U

Universal Care Dental #1C03011814 W Lincoln Ave 714-780-5665 F/T 4 P/T 4 (SP, TA, VI) U

Village Dental #0273341210 S Brookhurst St 714-535-7500 F/T 1 P/T 1 (AR, SP) U

APPLE VALLEYApple Valley Dental Office #00868918245 Us Highway 18 Ste 4 760-242-2977 F/T 3 P/T 1Apple Valley Dtl Associates #00914720162 Us Highway 18 Ste L 760-946-1466 P/T 2 (SP, KO)Apple Valley Smiles #02288912218 Apple Vly Rd Blg1 110 760-300-3678 P/T 2 (SP) U

Desert Dental Group #02416519195 Outer Hwy 18 Ste 201 760-242-0796 F/T 2 P/T 1 (TA)Haisam Sayed, DDSInc #02893418805 Bear Valley Rd Ste 4 760-961-7001 F/T 1 (AR, SP)Parkway Dental Group #02323520258 Us Highway 18 Ste 400 760-646-8839 P/T 2 (SP) U

ARCADIAArcadia Dental Center #196501440 E Huntington Dr Ste 101 626-447-5126 F/T 1 P/T 1 (KO, PE, SP) U

Arcadia Dental Group #028125111 E Live Oak Ave 626-445-1181 F/T 2 P/T 1 (SP, CH, VI, CA, AM)Drs Cheng & Kim #0174831043 W Huntington Dr 626-445-9660 F/T 1 P/T 1 (CA, KO, SP) U

Jason Gee DDSInc #029181638 W Duarte Rd Ste 9 626-447-7877 F/T 1

Kai Wu, DDS Inc #011037906 S Baldwin Ave 626-462-9890 F/T 1 (SP, CH, JA, TA)Live Oak Dental #026090288 E Live Oak Ave Ste C 626-898-0008 P/T 1Marc Rojtman, DDS #021394301 W Huntington Dr 626-445-3550 F/T 1 (FR, SP)Santa Anita Dental Group #018884721 W Huntington Dr Ste B 626-574-1766 F/T 1 P/T 1 U

William Houston, DDS #38620125 N Santa Anita Ave Ste E 626-254-1948 F/T 1ARLETAOsborne Dental Office Inc #00285213205 Osborne St Ste F 818-890-2426 F/T 1 (SP) U

Sima Boostanfar, DMD #0002239069 1/2 Woodman Ave 818-893-8799 F/T 1 P/T 1 (SP, PE)Woodman Family Dentistry #1986018725 Woodman Ave 818-891-6670 F/T 1 (SP)ARROYO GRANDEJeffrey Williams, DDS #286501236 S Halcyon Rd 805-489-1495 F/T 1ARTESIADr Moy DDSInc #02959511747 South Street 562-865-3635 F/T 1 (CA, SP) U

Egari Dental Office #01326218011 Pioneer Blvd # C 562-402-4492 F/T 1 (PE, SP)Sarah Cupino, DMD #00073312146 South St Ste E 562-924-1007 F/T 1 (SP, TA) U

Sioe Hwa Ong DDSInc #11220117906 Pioneer Blvd Ste 100 562-860-9612 F/T 1 P/T 1 (SP, TA) U

AzusaAngela Hoffman, DDSInc #011613483 S Citrus Ave 626-966-3400 F/T 1 (RU, SP) U

Apple Dental #002012891 E Arrow Hwy Ste B 626-332-4788 F/T 1 (SP)Bright Now Dental/Azusa #033796810 E Alosta Ave 626-804-2144 P/T 5 (CH, SP) U

Canyon City Dental Care #017992706 N Azusa Ave 626-334-7310 F/T 1 (SP) U

James Ahn, DDSInc #012598315 E Gladstone St 626-969-6728 F/T 1 (SP) U

Noble Dental Office #022978590 E Foothill Blvd 626-969-1116 P/T 1 (HI, SP)BAKERSFIELD17th Street Dental Care #0280071621 17th St 661-631-0529 P/T 1 U

Bakersfield Dental Group #0121365120 Stockdale Hwy Ste D 661-324-5442 F/T 1 (SP)Bhaskar Joshi, DDSInc #0134852519 River Blvd 661-873-9632 F/T 1 (HI, SP)Bright Dental Care #0265081120 Calloway Dr Unit 400 661-588-2772 F/T 1 (KO, SP) U

Centennial Dental Clinic #020011201 China Grade Loop 661-393-4333 P/T 2 (AR, SP)Crown Dental #0265746300 White Ln Ste C 661-827-1100 F/T 1 (SP, VI) U

Dedicated Dental #0141469600 Rosedale Hwy 661-589-5248 F/T 1 P/T 1 (SP) U

Dedicated Dental #0141478200 Stockdale Hwy Ste M9 661-834-9042 F/T 2 P/T 1 (KO, SP) U

Dedicated Dental #0141523150 Panama Ln Ste H 661-396-0156 F/T 2 P/T 3 (RU, SP) U

Dedicated Dental Calif Ctr #0131573400 Wible Rd 661-835-8672 F/T 1 P/T 2 (SP) U

East Hills Family Dentistry #0209382600 Oswell St Ste F 661-871-4132 P/T 1 (SP, TA)F M Hanna, DDS #0172903809 San Dimas St Ste A 661-322-7696 P/T 1 (AR, SP)G Street Family Dental #1C56012611 G St 661-859-0192 F/T 1Home Care Dental #0200145917 Niles St # 3 661-366-6527 F/T 1 P/T 1Mercy Plaza Dental Group #020863500 Old River Rd Ste 225 661-663-0109 F/T 2 (AM, GE, RU, SP)Millennium Dental Center #0330921830 28th St 661-326-8536 P/T 2 (AR, SP)River Lakes Dental Group #0129869510 Hageman Rd Ste B 661-829-2700 P/T 1 (VI) U

Robert Redelsperger, DDS #013335 2106 20th St 661-324-6053 F/T 1 (SP)Sian Poh, DDS #1641012721 H St 661-324-9709 F/T 1 (CH, SP)Smilecare-Bakersfield #0029732750 Ming Ave 661-396-1701 F/T 4 P/T 1 (SP) U

BALDWIN PARKBaldwin Park Family Dental #02989813020 Francisquito Ave Ste 7 626-962-9474 F/T 1 (SP, KO)David Kutner, DMD #05780113734 Ramona Blvd 626-960-6616 F/T 1 (KO, SP) U

Impressive Dental Care #03341614510 Towne Center Drive F2 626-851-4444 P/T 1 U

Prakash Patel, DDS #0003134138 Maine Ave Ste N3 626-960-6395 P/T 1 (SP)Ramona Family Dentistry #00398814325 Ramona Blvd 626-962-6814 F/T 1 (KO, SP) U

San Jose Young Dental #03135714514 Ramona Blvd Ste 1 626-337-4700 F/T 1 (KO, SP) U

West Coast Dental #0190014000 La Rica Ave Ste D 626-430-9171 F/T 1 P/T 1 (SP, CH) U

BANNINGDental Works #0042056350 W Ramsey St Ste A 951-769-0466 F/T 1 (SP)Pass Dental Group #0311544240 W Ramsey St 951-849-4484 P/T 1BARSTOWDr Salman Dental #023375927 Armony Rd 760-252-4488 P/T 1 (AR, SP)Procare Dental Grp #0239001232 E Main St 760-256-1189 F/T 1 (TA, SP) U

BEAUMONTBeaumont Dental Group #014131 930 Beaumont Ave 951-845-2200 F/T 1 P/T 2 (FR, HI, SP) U

Beaumont Smiles Dental Group #0269121620 E 2Nd St Ste A 951-769-9131 P/T 1 U

BELLBell Dental! #0134376633 Atlantic Ave 323-773-1000 F/T 4 P/T 6 (SP) U

Bell Plaza Dental Center #0214786343 Atlantic Ave Ste C 323-771-7226 F/T 1 (PE, SP) U

Dentalville #0233095021 Florence Ave 323-560-1508 P/T 2 (SP) U

Dr Desai-Gage Family Dental #0131444127 Gage Ave 323-773-2931 F/T 2 (Sp) U

Kamran Hakim, DDS #0122926334 Atlantic Ave 323-560-3646 P/T 1 (SP, PE)

La Familia Dental Group #0236464203 Gage Ave 323-312-0500 P/T 1St. Mary & St. George Dtl Ctr #0268566905 1/2 Atlantic Ave 323-773-5029 F/T 1 (PE, RU, SP) U

BELL GARDENSJin Wei Chu, DDS #3720016526 Eastern Ave 323-771-3949 F/T 2 (CH, SP)Marketplace Dental Office #3284016815 Eastern Ave Ste A1 323-560-2595 P/T 1 (SP) U

BELLFLOWERBellflower Dental #01992317615 Lakewood Blvd 562-408-1447 F/T 2 P/T 1 (SP)Bellflower Family Dtl Service #35970117019 Bellflower Blvd 562-866-9739 F/T 1 (SP, HI)California Dental Group #02382410106 Alondra Blvd # A 562-867-5117 P/T 1 (SP, KO)Crown Dental #0192339202 Alondra Blvd 562-866-8444 P/T 1 (SP, KO) U

Gerald Sandarg, DDS #18550117024 Clark Ave Ste C 562-925-7436 F/T 1 (SP)John Lim, DMD #32930110120 Alondra Blvd 562-920-6644 F/T 1 (SP) U

Michael Ahn, DDS #02149816106 Bellflower Blvd 562-920-9220 F/T 1 (KO, SP)Rosecrans Dental Group #0032089222 Rosecrans Ave 562-272-0222 P/T 6 (SP, VI) U

Smile Center Dental Group #01063416537 Bellflower Blvd Ste B 562-866-7073 P/T 1 (Pe, Sp) U

Smilecare-Bellflower #00448117240 Downey Ave 562-531-0221 P/T 4 (SP)Somerset Dental #0175309426 Somerset Blvd 562-925-3735 P/T 1 (CH, SP) U

Universal Care Dental #1C090117660 Lakewood Blvd 562-461-1180 F/T 3 P/T 5 (SP, TA, VI) U

BEVERLY HILLSBedford Dental Group #013340432 N Bedford Dr 310-278-0600 F/T 1 (GE, PE, SP) U

Bedford Dental Group #018257432 N Bedford Dr 310-278-2424 F/T 1 (PE, GE) U

Beverly Hills Cosmetic Dental #0054839400 Brighton Way Ste 309 310-273-7397 F/T 1 P/T 2 (RU, SP)Clay Loveday, DMD #017520416 N Bedford Dr Ste 209 310-248-3607 F/T 1 U

David Abri DDSInc #01989150 N La Cienega Blvd Ste 217 310-275-0032 P/T 1 (PE, SP) U

Dental Group of Beverly Hills #146801250 N Robertson Blvd Ste 412 310-271-3003 F/T 1 P/T 1 (AM, PE, SP) U

Dental Group of Beverly Hills #00354599 N La Cienega Blvd Ste 300 310-289-1818 P/T 1 (SP, TA) U

Jjp Dental #021771435 N Bedford Dr Ste 108 310-276-2009 F/T 1Kambiz Kashfian, DDS #30500150 N La Cienega Blvd Ste 206 310-659-7949 F/T 1Naomeh Mashhood, DDS #0165688500 Wilshire Blvd Ste 602 310-289-1101 P/T 1 U

Pacific Dental Care #3630019025 Wilshire Blvd Ste 315 310-274-7485 F/T 1 P/T 1 (SP) U

Roxbury Dental #0054609100 Wilshire Blvd Ste 363W 310-553-8188 F/T 1 U

Smile Angels of Beverly Hills #0263478500 Wilshire Blvd Ste 709 310-201-9001 F/T 1 U

Steven Goldy and Assoc #255201416 N Bedford Dr Ste 409 310-550-1511 F/T 1 (SP)BLOOMINGTONJack Ackerman, DDS #370001993 W Valley Blvd Ste 103 909-877-3660 F/T 1 (SP) U

BONITABonita Family Dental #0132834424 Bonita Rd 619-479-8703 F/T 2 P/T 2 (SP, TA, RU, HI)BREABerry Imperial Dental Group #1C4801649 W Imperial Hwy Ste H 714-529-1232 F/T 1 P/T 1 (CH, SP, HI) U

Brea Dental Arts #025702710 N Brea Blvd Ste E 714-529-8558 P/T 2 (SP, CA, CH)Brea Dental Group #007310503 E Imperial Hwy 714-672-9000 F/T 1 P/T 1 (AR, SP, VI) U

Brea Dentistry #022863782 N Brea Blvd 714-257-0330 P/T 1 U

Harin Shodhan, DDS #026114936 E Imperial Hwy 714-990-4911 F/T 1 (SP) U

Imperial Dental Care #3C1501200 E Imperial Hwy 714-671-9999 F/T 1 P/T 1 (FR, SP, HI, VI)Sheena Bhatia, DDS #025689151 S Kraemer Blvd Ste C1 714-257-9200 F/T 1 (SP, HI) U

William Lou, DDS #152701552 E Lambert Rd 714-990-3344 F/T 1BUENA PARKForoutan Dental Corporation #0123538951 Knott Ave Ste L 714-826-4181 F/T 2 (PE, SP)Mona Fahmy, DDS #0016878402 Commonwealth Ave 714-739-2051 F/T 1 (AR, FR, SP, VI)P Dholakiya & Associates DDS #0299697011 Orangethorpe Ave # 100 714-994-4482 P/T 2 (HI, SP) U

Plaza Dental Care #0156608575 Knott Ave Ste A 714-761-8575 F/T 1 (KO, SP) U

St Therese Family Dentistry #1570016891 La Palma Ave 714-994-6911 F/T 1 (TA)Valley View Dental #02329810102 Valley View St 714-229-4898 P/T 1 (SP, HI, GE, RU) U

West Coast Dental #0146318381 La Palma Ave 714-228-9990 P/T 3 (SP) U

BURBANKBoyajian/ Bardakjian, DDS #0246603808 W Riverside Dr Ste 307 818-861-7840 F/T 2 U

Burbank Village Dentistry #017970928 N S F Blvd Ste E 818-841-8607 P/T 1 (RU, SP) U

Burbank/Glendale Dental Group #013523500 E Olive Ave Ste E430 818-567-4662 P/T 2 (PE, AM, SP) U

Burbank-Glendale Dental Group #013438216 E Alameda Ave 818-848-3026 P/T 1 (AM, SP, TA, PE, RU) U

Castle Dental Center #015675140 N Victory Blvd Ste 101 818-841-1634 F/T 4 P/T 8 (SP) U

Empire Dental Group #0115281635 N Victory Pl 818-565-0057 F/T 1 P/T 1 (AM, PE, SP) U

Harold A Lubick, DDS, MD #022119500 E Olive Ave Ste 440 818-848-5591 F/T 1 U

Hi Care Dental #017782354 E Angeleno Ave 818-846-4206 F/T 1John Yekikian, DDS #2360012601 W Alameda Ave Ste 406 818-843-7841 F/T 1 (AM, SP)Louis Mo, DDS #011035500 E Olive Ave Ste 460 818-846-3181 F/T 1 (SP) U

Mylene Nguyen, DDS #0318582720 W Magnolia Blvd 818-842-4879 P/T 1


1324

6 A benefit for permanent teeth only.7 Includes after delivery adjustments and tissue conditioning,

if needed, for the first six months after placement, if the Enrollee continues to be eligible and the service is provided at the Contract Dentist’s facility where the denture was originally delivered.

8 Replacement is subject to a limitation requiring the existing denture to be 5+ years old.

9 Limited to 1 per denture during any 12 consecutive months.10 Replacement is subject to a limitation requiring the existing

bridge to be 5+ years old.11 Listed Copayment covers up to 24 months of active

orthodontic treatment excluding the services listed for D8999 (Start-up fee). Beyond 24 months of active treatment, an additional monthly fee of $75.00 applies.

12 In the event comprehensive orthodontic treatment is not required or is declined by the Enrollee, a fee of $25.00 will apply. The Enrollee is also responsible for any incurred orthodontic diagnostic record fees.

13 Includes adjustments and/or office visits up to 24 months. After 24 months, a monthly fee of $75.00 applies.

Star Dental Practice #0099798626 Lower Sacto Rd Ste 37B 209-951-8088 F/T 1 (HI, CH, SP, TA) U

Stockton Dental Group #0096651036 W Robinhood Dr Ste 104 209-956-9650 P/T 1 (SP)SUNNYVALEGentle Dental Sunnyvale #0096191639 Hollenbeck Ave 408-732-6931 F/T 1 P/T 2 (SP, TA, VI, HI, RU)Joon Ku Lee, DMD #009540990 W Fremont Ave Ste T 408-774-2828 F/T 1 (KO)Lora Costa, DDS #0091361286 Kifer Rd Ste 110 408-774-1200 P/T 1 (SP, TA, VI) U

Navjyot Panjrath, DDS #009135689 E Remington Dr Ste B 2 408-739-6521 F/T 1Sai Dental #0090321050 E El Camino Real 408-423-9197 F/T 1 (HI, PE)Smilesavers Dental #0090221214 Apollo Way Ste 402 408-737-0101 F/T 1Sunnyvale Dental Aesthetics #009015 1286 Kifer Rd Ste 105 408-736-8880 P/T 1 (CH, SP) U

Sunnyvale Family Dtl Care #008953990 W Fremont Ave Ste 0 408-739-8999 F/T 1 (SP)TRACYBrite Smiles Dentistry #0089071170 W 11th St 209-839-1600 F/T 1 (HI, SP)California Dental Group #0088723101 N Tracy Blvd 209-830-7473 F/T 1 U

Grantline Dental #0086872242 W Grant Line Rd Ste 102 209-832-2525 F/T 1 (HI, SP, TA, CH, TH) U

Paramjit Singh, DDS #0085384598 S Tracy Blvd Ste 150 209-221-6666 F/T 1 (HI, TA, SP) U

Smilecare-Tracy #0084542990 W Grant Line Rd 209-830-7797 F/T 5 P/T 3 (SP) U

Tracy Dental #0084282135 N Tracy Blvd 209-836-4950 F/T 1 P/T 2 (SP, TA) U

Tracy Smiles Dtl Grp #0082482600 S Tracy Blvd Ste 170 209-836-5441 P/T 1 (SP) U

University Dental #007823530 W Eaton Ave Ste L 209-839-8810 P/T 1 (SP, PE)TURLOCKHealthy Smile Dental #007289241 N Palm St 209-668-9300 P/T 2 (CH, HI, SP, TH)Monte Vista Dental #0072863212 W Monte Vista Ave 209-669-6500 P/T 1 (RU, SP, HI) U

UNION CITYShine Dental #00728434665 Alvarado Niles Rd 510-441-7645 F/T 1 (AR, HI, PE) U

Trinh Trac, DDS #00728233448 Alvarado Niles Rd 510-429-1178 F/T 1 (CA, VI, SP) U

VACAVILLEAlamo Family Dental Care #0072713000 Alamo Dr Ste 203 707-454-3888 F/T 1 P/T 3 U

Alamo Plaza Dental Office #005955810 Alamo Dr 707-469-8188 P/T 1 (SP, TA) U

All Smiles Dental #005532 1241 Alamo Dr Ste 11 707-447-8289 P/T 1 (SP) U

Bayside Dental #00553172 Peabody Rd 707-450-0732 F/T 1 (SP, TA, FR) U

Vacaville Dental Associates #005507412 Cernon St Ste A 707-452-0445 P/T 1 (PE, SP, TA) U

VALLEJOAccess Dental #0049273400 Sonoma Blvd 707-554-4000 F/T 1 P/T 4 (PE, SP, TA) U

Bayside Dental #0046532121 Redwood St Ste A 707-644-7600 P/T 1 (PE, SP, TA) U

Ec Dental Care #0044983315 Sonoma Blvd Ste 50 707-552-4800 F/T 1 (SP, TA) U

Julius Mosley II, DDS #0044972121 Redwood St Ste E 707-558-1660 F/T 1 U

Setty DDS Inc #003967480 Redwood St Ste 13 707-554-2600 P/T 1 (HI, TA, VI)Smilecare-Vallejo #003724133 Plaza Dr Ste R 707-557-6245 F/T 5 P/T 6 (SP)Vallejo Dental Associates #003718475 Redwood St Ste 30 707-643-1714 P/T 1 (PE, SP, TA)VISALIAAbc Dental Group #003503 2548 S Mooney Blvd 559-733-9797 F/T 2 (SP) U

Cosmetic Touch Dental Group #0029872634 W Walnut Ave 559-732-7224 P/T 1 (AM, SP)Visalia Dental #0027065344 W Cypress Ave Ste 101 559-635-4391 F/T 2 P/T 4 U

Visalia Family Dentistry #0022371644 W Caldwell Ave Ste A 559-740-0444 P/T 1 (TA, SP)WALNUT CREEKDaniel R Pestana, DDS #0019782255 Ygnacio Valy Rd Ste J2 925-945-8006 F/T 1 (SP) U

Dental Care Of Walnut Creek #0017041111 Civic Dr Ste 145 925-937-9017 P/T 2 (CH, HI, SP) U

Horizons Dental #0015041479 Ygnacio Valy Rd Ste 107 925-945-7977 P/T 2 (CA, SP) U

Mikhail Berdichevsky, DDS #001493120 La Casa Via # 105 # Via 925-933-9820 F/T 2 (RU) U

San Miguel Dental #0011591844 San Miguel Dr Ste 206 925-279-3326 F/T 1 P/T 2 (SP) U

Spring Dental #0011582987 N Main St 925-930-7770 F/T 1 (PE, SP) U

Tim Patel, DDS #0011571818 San Miguel Dr 925-945-7366 F/T 1 U

WATSONVILLECrossroads Dental #0008981951 Main St 831-761-9500 F/T 1 (SP) U

WEST SACRAMENTOAcme Dental #000893820 Westacre Rd 916-371-1500 F/T 1 P/T 1 (SP, PE) U

Dentistry Today #0007981001 Jefferson Blvd Ste 500 916-372-7022 F/T 1 U

South River Dental Group #0006692455 Jefferson Blvd Ste 130 916-372-8062 P/T 2 (SP) U

Vivian Fernandez, DDS #000594821 Jefferson Blvd 916-372-3368 F/T 1 (AM, RU, SP)WOODLANDCottonwood Dental Group #000286520 Cottonwood St Ste 4 530-669-6688 F/T 1 (SP, CH, HI, TA) U

Lincoln Dental #000221520 Cottonwood St Ste 11 530-661-9276 F/T 4 (SP) U

Yolo Dental Practice #000218520 Cottonwood St Ste 9 530-662-8100 F/T 2 (CA, SP, TA) U

YUBA CITYAccess Dental #000070940 Colusa Ave Ste A 530-755-9900 F/T 1 P/T 3 (SP)Melissa Lee, DDS #0000661215 Plumas St Ste 1901 530-751-7671 F/T 1 (CA, SP) U

ALAMEDABay View Dental #0329622181 Harbor Bay Pkwy 510-523-2188 F/T 1 Ca, Sp, Vi U

APTOSSam Christensen, DDS #0164097545 Soquel Dr Ste B 831-688-7878 F/T 1CLEARLAKELakeshore Dental Practice #00298615322 Lakeshore Dr Ste 104 707-994-6050 F/T 1 U

CLOVISMichael Ward, DDS #152901375 Bullard Ave Ste 3 559-298-7424 F/T 1 (SP) U

CONCORDDarryl Burke, DDS #1651013600 Concord Blvd 925-691-0238 F/T 2Robert Hlavac, DDS #1394012917 Salvio St Ste B 925-689-1772 F/T 1 (GE, SP) U

ELK GROVETerri Speed & Associates #0220969098 Laguna Main St Ste 4 916-691-1600 P/T 1 (SP) U

Terri Speed, DDS Inc #0220979381 E Stockton Blvd Ste 120 916-686-4212 P/T 2 (SP) U

EUREKAStephen Angeloff, DDS #0236923125 G St 707-445-4300 F/T 1 (SP)Victoria Place Dental Center #0029723144 Broadway Ste C1 707-443-9374 F/T 1 U

FAIRFIELDParkside Dental Team #0765011325 Travis Blvd Ste D 707-427-2222 F/T 3 (Sp) U

FOLSOMSummit Dental #15910125004 Blue Ravine Rd Ste 111 916-355-8400 F/T 1 (PE, SP, RU) U

FREEDOMFamily Dental Center #155701122 Thicket Ln 831-724-6000 F/T 1 (SP)FREMONTKamlesh Jinjuwadia, DDS #1353013500 Mowry Ave Ste A 510-796-1499 F/T 1 (SP)Mission Dental #00673339560 Stevenson Pl Ste 218 510-494-8856 F/T 1 (SP)Precious Dental Care #0107053200 Mowry Ave Ste A 510-790-7900 F/T 1FRESNOKimmer Young, DDS #0146321431 W Shaw Ave 559-229-5930 F/T 1Rachel Jack, DDS #0265734747 N 1st St Ste 113 559-225-4540 F/T 1 Sp U

Sidney Jackson, DDS #1615017433 N 1st St Ste 101 559-447-3003 F/T 1 (SP) U

Snr Dental #0141537472 N Fresno St Ste 201 559-438-8686 F/T 1Thomas Downing, DDS #0265704747 N 1st St Ste 113 559-225-4540 F/T 1 (SP) U

GRANITE BAYAdvanced Dental Care #0224166910 Douglas Blvd Ste F 916-780-7676 F/T 1 (SP, RU) U

MADERAKimmer Young, DDS #0105492401 W Cleveland Ave 559-673-4075 F/T 1 P/T 1 (AR, FR, SP) U

MILPITASAlexander Galang, DDS #391301830 Hillview Ct Ste 150 408-934-7676 F/T 1 (TA)Liberty Plaza Dental Center #0158071252 S Abel St 408-945-4444 P/T 2Vincent Liang, DDS #021680106 Dixon Rd 408-934-1200 F/T 1 (CA, CH) U

MODESTOAccord Dental #0324154120 Dale Rd Ste J6 209-543-9999 F/T 1 (HI, SP) U

MOUNTAIN VIEWParktown Dental Care #170301990 Bay St 650-968-4000 F/T 1 (Sp, Vi) U

OAKLANDGentle Dental #1670011624 Franklin St Ste 615 510-451-7881 F/T 1 P/T 4 (CA, SP)PACHECOPacheco Family Dentistry #145901218 Center Ave 925-671-9900 P/T 1 U

REDDINGEric R Waits, DMD #0210462115 Eureka Way 530-246-1142 F/T 1 (GE, TA)ROCKLINJeffrey Routsong, DDS #0327655800 Stanford Ranch Rd # 510 916-435-3060 F/T 1 (SP) U

ROSEVILLESierra College Dtl Practice #0006679290 Srra Colg Blvd Ste 300 916-788-8450 F/T 2 (SP, VI) U

SACRAMENTOA+ Dental #0239443307 Alta Arden Expy 916-974-1819 F/T 1 (GE, KO, SP)Adriane Scortia, DDS #1333014611 Freeport Blvd Ste 5 916-451-4432 F/T 1 (RO, RU)SAN JOSEBlossom Hill Family Dental #1624015058 Union Ave Ste A 408-559-8668 F/T 1 (VI) U

Daniel Thompson, DDS #2076015710 Cahalan Ave Ste 5A 408-281-0500 F/T 1Evergreen Valley Dental #0118644868 San Felipe Rd Ste 120 408-528-8303 F/T 1 (HI, VI)Ever-Smile Dental Care #0113182910 Stevens Crk Blvd # 208 408-296-9900 F/T 1 (HI, SP)Rosalinda Hopkins, DMD #0040596199B Santa Teresa Blvd 408-972-8077 F/T 1 (TA)SAN LEANDROCorey Jang, DDS #374301433 Estudillo Ave Ste 302 510-351-0930 F/T 1 (CH, TA) U

Margaret Yap, DDS #17600113770 Doolittle Dr 510-352-3918 F/T 1 (CH, SP, TA)SAN MATEODeepak Sachdev, DDS #0016521415 S El Camino Real 650-573-6500 P/T 1 (SP)SAN RAFAELMarin Dental Care #0103904050 Redwood Hwy Ste A 415-499-7700 F/T 1 P/T 1 (SP, CH, TA) U

SANTA CLARAColeman Family Dental #0299841341 Coleman Ave 408-844-9578 F/T 1 (TA)De La Vega Dental Corp #0142671210 Homestead Rd 408-260-7384 F/T 1 (SP, TA) U

Santa Clara Family Dental #0283962725 El Camino Real Ste 109 408-241-4111 F/T 3 (PE, SP)Thomas Puzin, DDS #260501545 Saratoga Ave Ste B 408-247-5442 F/T 1 (SP)STOCKTONM Luisa Bermudez, DMD #137801221 Tuxedo Ct Ste D 209-466-0254 F/T 1 (TA)SUNNYVALEPalm Bay Dental #0027091301 Snvl Saratoga Rd # 2 408-732-2112 F/T 1 (SP, VI) U

Stephen Fong, DDS #0C9501990 W Fremont Ave Ste S 408-736-4101 F/T 1TURLOCKColorado Family Dentistry #0046152150 Colorado Ave 209-668-9442 F/T 1 (SP)Delbon Dental #0236271060 Delbon Ave 209-667-2977 P/T 1 (AR, SP) U

VACAVILLEAlamo Dental #0214263057 Alamo Dr 707-448-8881 F/T 2 (TA, SP) U

Glenn Fung, DMD #019513885 Markham Ave 707-448-8851 F/T 1 (SP) U

VALLEJOTri-City Dental Vallejo #0228963630 Sonoma Blvd 707-643-1987 F/T 1 (SP) U

ACTONSoo Park, DDS #03113433342 Santiago Rd 661-269-4200 F/T 1AGOURA HILLSAgoura Dental #02209130313 Canwood St Ste 36 818-735-3800 F/T 1 (GE, PE, SP)Agoura Family Dental #02348229219 Canwood St Ste 250 818-991-2626 P/T 1 (PE, SP, TA) U

Sea Breeze Dental Care #00662929525 Canwood St Ste 200 818-991-9852 F/T 2 P/T 2 (AM, PE, RU, SP) U

ALHAMBRAAlhambra Family Dentistry #118001600 W Main St Ste 102 626-282-4119 F/T 1 (SP) U

Drs Lee and Yee #051601157 N Garfield Ave 626-284-5113 F/T 2 P/T 1 (CH, SP) U

Jin Zhang, DDS #0259391711 W Main St 626-308-1711 F/T 1Mohammad Dabbousi, DDS #000647401 N Garfield Ave Ste 5 626-570-0974 F/T 1 (AR, TA) U

Nadir Yazdani, DDS #0C0201747 S Garfield Ave 626-289-6815 F/T 2 (EI, SP)ALISO VIEJOAll Smile Dental Group #02649222912 Pacific Park Dr Ste A 949-716-6900 F/T 1 (CH, SP) U

Claire Cho, DDS #0038212 Mareblu Ste 200 949-831-8826 F/T 1 (KO, PE, SP, TA) U

Duong & Petchpud DDS #0331955 Journey Ste 250 949-360-1021 P/T 2 (PE, SP, TH, VI) U

ALTA LOMACarnelian Family Dentistry #1988016626 Carnelian St 909-987-4113 F/T 1 (Ch, Sp)Jia Lee, DDS #0049569320 Baseline Rd Ste E 909-989-5598 P/T 2ANAHEIM7 Day Dental #0137702265 W Lincoln Ave 714-491-8600 F/T 1 P/T 6 (CH, TA, SP, VI) U

Anaheim Community Dentistry #013480435 N State College Blvd 714-635-0855 P/T 1 (PE, SP, VI) U

Anaheim First Family Dental #2565011161 N Euclid St 714-999-5050 F/T 1 P/T 1 (SP)Anaheim Hills Dental Group #3C22015731 A-5701 Santa Ana Cyn Rd 714-998-2956 P/T 2 (SP)Anaheim Open 7 Days Dental #274701637 N Euclid St 714-772-2893 F/T 1 P/T 6 (AR, PE, TA) U

Bright Now! Dental #004784150 N State College Blvd 714-491-8441 F/T 6 P/T 13 (SP, VI) U

Ca Dental Group of N Anaheim #0086711221 N Euclid St 714-491-2732 P/T 1 (SP, VI) U

Care Dental #0210503203 W Ball Rd 714-995-3415 F/T 2 (VI) U

Charles Kimball, DDS #032294 522 N Magnolia Ave 714-828-1415 F/T 1 P/T 1 (SP, TA)Coastal Dental Care #007875922 S Euclid St 714-776-7015 F/T 1 P/T 2 (SP) U

Coastal Dental Care #0078762300 S Harbor Blvd 714-750-3030 F/T 1 P/T 1 (SP, VI) U

Danny Thomas, DDS #188001601 S Euclid St 714-778-0700 P/T 1 (RU, SP, VI)Dental Care of Anaheim #258301815 N Euclid St 714-758-0791 F/T 2 P/T 1 (SP, HI) U


Northern CaliforniaOffices (Closed)

Southern CaliforniaOffices (Open)

SCHEDULE BLIMITATIONS OF BENEFITS1. Full mouth x-rays are limited to one set every 24 consecutive

months and include any combination of periapicals, bitewings and/or panoramic film.

2. Bitewing x-rays are limited to not more than one series of four films in any six month period.

3. Diagnostic casts are limited to aid in diagnosis by the Contract Dentist for covered benefits.

4. If a biopsy is preauthorized by Delta Dental for an oral surgeon, then examination of the resulting biopsy specimen is covered under codes D0472, D0473 or D0474 and available at no additional cost.

5. Prophylaxis or periodontal maintenance is limited to two procedures each 12 month period.

6. Benefits for sealants include the application of sealants only to permanent first and second molars with no decay, with no restorations and with the occlusal surface intact, for first molars and second molars through age 15. Benefits for sealants do not include the repair or replacement of a sealant on any tooth within three years of its application.

7. A filling is a benefit for the removal of decay, for minor repairs of tooth structure or to replace a lost filling.

8. A crown is a benefit when there is insufficient tooth structure to support a filling or to replace an existing crown that is non-functional or non-restorable and meets the five year limitation (see Limitation #12).

9. A covered metallic inlay, onlay, crown or fixed partial denture (bridge) using base or noble metal is available for listed Copayment(s). If the Enrollee elects to have high noble metal used instead, the maximum additional cost of this material upgrade is $100.00 per tooth or pontic. For an indirectly fabricated post and core, the benefit is for base or noble metal. If the Enrollee elects to have a high noble metal indirectly fabricated post and core instead, the maximum additional cost of this material upgrade is $100.00 per tooth.

10. For molars, a covered crown or unit of a fixed partial denture (bridge) is a full cast metal restoration without porcelain or other tooth-colored material. If the Enrollee elects to have porcelain, porcelain-fused-to-metal, resin or resin-with-metal used instead, the maximum additional cost for this tooth-colored material upgrade is $150.00 per molar.

11. If a porcelain margin is also chosen by the Enrollee for a covered porcelain-fused-to-metal crown, the maximum additional cost for this laboratory upgrade is $75.00.

12. The replacement of an existing inlay, onlay, crown, fixed partial denture (bridge) or a removable full or partial denture is covered when:

a. The existing restoration/bridge/denture is no longer functional and cannot be made functional by repair or adjustment, and

(continued)

2314

Irvin Ramsey, Dds #023474 905 Secret River Dr Ste C 916-393-2587 U

Lp Dental Care of Loan Pham #0234596830 Stockton Blvd Ste 185 916-422-5628 F/T 1 (VI) U

Madison Dtl Care #0232885149 Madison Ave 916-338-3880 F/T 1Market West Dental Group #0232683290 Arena Blvd Ste 610 916-574-9400 F/T 1 P/T 1 (SP) U

Miracle Smile-Dezham Dntl Grp #0232272131 Capitol Ave Ste 100 916-441-3311 F/T 2 (PE, RU, SP) U

More Smiles Dental #0231902020 Hurley Way Ste 135 916-641-7700 F/T 1 U

Natomas Dental Care #0231872321 Northgate Blvd 916-564-8088 P/T 1 U

New Dental Images #0231386624 Valley Hi Dr 916-688-1990 F/T 1 (SP, TA, VI)Odean Loney, DMD #023129905 Secret River Dr Ste A 916-428-5318 F/T 1 U

Pacific Plaza Family Dental #0231286930 65th St Ste 107B 916-422-5697 F/T 2 (CH, SP, VI) U

Park Place Dental Group #0230074690 Natomas Blvd Ste 100 916-515-4500 P/T 1 U

Paul Shieh, DDS #0228675659 Stockton Blvd 916-456-8625 F/T 1Pioneer Family Dental #0228587850 Stockton Blvd Ste 160 916-689-3310 F/T 3 (CH, PE, SP, TA, VI) U

Pro Dental Group #022838 1111 24th St Ste 201 916-442-5228 P/T 1 U

Promenade Dental Group #0227523635 N Freeway Blvd Ste 110 916-285-6691 P/T 2 (Sp) U

Sacramento Dental #022751591 Watt Ave Ste 100 916-481-5057 P/T 3 (SP)Sacramento Dental Arts #0227503428 Watt Ave Ste B 916-489-9990 P/T 2 (SP)Said Shaari, DDS #02264077 Cadillac Dr Ste 270 916-649-8200 P/T 1 (CH, PE, RU, SP)Sandhu Dental Group #0224843811 Florin Rd Ste 8 916-392-7020 P/T 1 (SP, HI) U

Scripps Dental Group #02246279 Scripps Dr Ste 204 916-565-2570 P/T 1Serena Pugeda, DMD #0217932518 L St Ste A 916-446-7768 F/T 3 (TA)Signature Dental #0216964321 Truxel Rd Ste F5 916-515-1588 F/T 1 (VI) U

Smile Makers #0216921906 Del Paso Rd 916-263-9888 P/T 3 (CH, CA) U

Stonebrook Dental #021635911 Howe Ave 916-920-1170 F/T 1 (HI, SP) U

Strawberry Creek Dental Grp #0214898211 Bruceville Rd Ste 155 916-525-7635 F/T 1 P/T 1 U

Unique Dental #0214227300 Franklin Blvd Ste 104 916-428-4325 F/T 1 P/T 1 (SP, TH, CH, GE, RU)Vicente Alindogan, DDS #0214218876 Vintage Park Dr Ste 105 916-681-2751 F/T 1 (TA) U

VP Dental Care #0213913337 El Camino Ave 916-486-8240 F/T 1 (SP, VI) U

West Florin Dental #021389930 Florin Rd Ste 100 916-706-1915 F/T 1 (SP, VI)Yolanda Gonzales, DMD #0211492378 Fruitridge Rd 916-421-1010 F/T 1 U

SALIDASalida Dental Group #0210485708 Pirrone Rd 209-543-3888 F/T 1SALINASDiamond Dental of Salinas #0210471209 N Davis Rd 831-424-4111 F/T 1 U

Peter Yang, DDS #02100411 Maple St Ste E 831-753-6598 F/T 1 (SP)Steinbeck Cntry Dtl Practice #020997535 E Romie Ln Ste 10 831-758-5836 F/T 2 (SP)SAN BRUNOEugene Espiritu #0209951230 El Camino Real Ste K 650-875-6808 P/T 1 (SP)San Bruno Dental Care #020994211 El Camino Real 650-589-4784 F/T 2 (GE, SP, TA) U

SAN FRANCISCOBernardo Gonzalez, DDS #0209432720 24th St 415-282-4566 F/T 1 (SP)Center of Cosmetic Dentistry #0209421550 Lombard St 415-921-5555 P/T 1Gentle Dental #0205172494 Mission St 415-821-1200 F/T 6 P/T 4 (RU, SP)Gentle Dental San Francisco #0203542364 Geary Blvd 415-921-6722 F/T 1 P/T 2 (CA, CH)Grand Mission Dental Group #0203224749 Mission St 415-469-7444 F/T 2 (TA, SP)Hipolito Baronia, DDS #020283 2480 Mission St Ste 214 415-821-7847 F/T 1 (SP, TA)J T Dental #0199852415 Noriega St 415-682-2415 F/T 1 (CA)Kayvan Kafayi, DDS #019966450 Sutter St Rm 1433 415-398-2360 F/T 1 (CH, FR, GE, IT, PE, SP)Mat Kiisk, DDS #0199603100 19ThAve 415-584-2537 F/T 2 (SP, TA, HI, JA)Melissa Chavez, DDS #0196902460 Mission St Ste 201 415-821-0101 F/T 1Michael Cole, DDS #0196332595 Mission St Ste 308 415-647-9191 F/T 1 (SP)Mikhail Berdichevsky, DDS #019514 4444 Geary Blvd Ste 303 415-386-5590 F/T 1 P/T 1 (RU) U

Noriega Dental #0194203749 Noriega St 415-661-8851 F/T 1 (CH)Ocean View Dental #019254760 La Playa St 415-221-5592 F/T 2 P/T 1 (CH, RU, SP, TA)Richmond Dental Care #0192534312 Geary Blvd 415-752-5605 F/T 2 (CH, RU, SP) U

Roberto Calabio DMD Inc #0192423184 22Nd St 415-642-2050 F/T 1 (TA)Ronald Young, DDS #0192401637 Lombard St 415-928-3777 F/T 1 (CH, SP)San Bruno Ave Dental Clinic #0190492817 San Bruno Ave 415-656-2868 F/T 1 (CH) U

South Van Ness Dental Group #019048240 Shotwell St Ste 230 415-431-9797 F/T 1 P/T 1 (CH, VI)Van Ness Dental Group #0190472243 Van Ness Ave Ste 101 415-441-2098 F/T 4 (CA, CH, SP, VI)SAN JOSEAdrienne Van, DDS #0189282114 Senter Rd Ste 14 408-298-9951 P/T 1 U

Afshin Abdollahi, DDS #0185751300 Meridian Ave 408-979-0808 F/T 1 P/T 1 (PE, SP)

All Star Dental #018513259 Meridian Ave Ste 12 408-275-0768 F/T 1 (PE, SP, TA)Berryessa Fmly Dentistry #0185112664 Berryessa Rd Ste 201 408-272-2330 P/T 1 (TA, SP)Big Smiles Dental Care #0182641547 Saratoga Ave 408-725-3740 F/T 1Comfort Dental Group #0181692881 Hemlock Ave # A 408-249-8888 F/T 1 (PE, VI, TA)David Meng, DDS Inc #0180462505 Samaritan Dr Ste 308 408-356-3588 P/T 1Dental Concepts Eastridge #017745 2200 Eastridge Loop Ste 1060 408-238-6684 F/T 1 (CH, SP, KO, HI, TA, VI) U

Evergreen Dental Grp #017744 3162 Newberry Dr 408-274-9600 F/T 1 (SP)Fariba Alikhani, DMD #017703 3575 Stevens Creek Blvd # L 408-247-3400 F/T 1 (SP, PE, TA)Gurdip Narula, DDS #0176662850 Quimby Rd Ste 145 408-274-5000 F/T 4 (HI, SP, TA) U

Healthy Smiles Family Dent #0176042664 Berryessa Rd Ste 107 408-258-1323 F/T 1 (HI, SP) U

Huong Nguyen, DDS Inc #017551266 N Jackson Ave Ste 3 408-258-2207 F/T 1 (SP, VI)Image Dental #0175482493 Alvin Ave 408-223-0988 P/T 1 (SP, VI)Irma Francisco DDS Inc #0174814750 Almaden Expy Ste 152 408-264-5880 F/T 1 (CA, JA, SP, TA, VI)Jackson Family Dental #0174692324 Montpelier Dr Ste 3 408-937-5950 F/T 2 (SP)Jasna Galeb, DDS #0174291547 Saratoga Ave 408-725-8331 P/T 1 (HR, RU)Joel Santos, DDS #017363200 N Jackson Ave Ste D 408-254-7491 F/T 1 (TA)John Tanaka, DDS #0172462034 Forest Ave Ste 1A 408-279-8080 F/T 1 (JA, KO, SP, HI)John Vu, Dds #0172211399 S Wnchester Blvd # 120 408-370-7767 P/T 1 (VI, SP) U

Kini Dental Care #017161 100 Oconnor Dr Ste 23 408-998-8383 F/T 1 (HI, SP) U

Kini Gentle Dental Care #017147827 Blossom Hill Rd Ste W5 408-226-1060 P/T 1La Amistad Dental Office #01684922N White Rd 408-254-4402 F/T 1 (SP)Lexann Dentals Corp #0167701569 Lexann Ave Ste 108 408-270-4211 F/T 1 (SP, VI) U

Muu Vu, DDS #0165692340 Mckee Rd Ste 3 408-923-6400 P/T 1 (VI, SP) U

Muu Vu, DDS #0162381569 Lexann Ave Ste 102 408-223-0104 P/T 1 (SP, VI) U

Ngoc Ly Pham, DDS #016236648 E Santa Clara St 408-287-0913 F/T 1 (SP, VI)Oakridge Dental #0162045450 Thornwood Dr Ste B 408-360-0270 F/T 1 (SP, PE, RU, HI) U

One Stop Dental #0161751155 S King Rd 408-928-5678 F/T 2 (CH, SP, VI)Portia Dela Vega Oblea DMD #0161732356 Senter Rd 408-993-9939 F/T 1 (SP, TA)Pro-Tech Dental Care #0158652664 Berryessa Rd Ste 210 408-258-8903 F/T 1 (VI, TA) U

Quach DDS A Professional Corp #01568088 Tully Rd Ste 103 408-279-9888 P/T 1 U

San Jose Dental #0156772930 Aborn Square Rd 408-238-1853 F/T 4 P/T 2 U

Setty Dental Corporation #0155721705 Branham Ln Ste B30 408-264-7630 F/T 1 P/T 1 (HI, SP, TA, VI) U

Silicon Dental #0154322060 Aborn Rd Ste 210 408-238-5500 P/T 1 (HI, SP)Smilecare-San Jose II #0154315130 Stevens Creek Blvd 408-557-9830 F/T 3 P/T 4 (SP)Story Dental Health Cntr Inc #0154302454 Story Rd 408-272-0888 F/T 1 P/T 1 (SP)Tianna Dao, DDS #0153992344 Mckee Rd Ste 10 408-926-9300 F/T 1 (SP, VI)Tuyen Nguyen, DDS #015202634 E Santa Clara St 408-286-6156 F/T 1 (VI, FR, SP)Uni Dental #014891175 S Capitol Ave Ste E 408-923-3073 F/T 1 (SP, VI)Unident #0148772390 Senter Rd 408-298-6420 P/T 1 (PE, SP, VI)Unismile Dental #0148766134 Camino Verde Dr Ste G 408-226-1600 F/T 1 (HI, SP, TA) U

Valley Dental Plaza #0146301664 Story Rd 408-937-9849 F/T 1 (SP, TA) U

Valley Family Dental Care #0146292060 Aborn Rd Ste 150 408-239-0816 F/T 1 (VI)William Thai, DDS #014628 630 E Santa Clara St 408-995-5424 F/T 1 (VI)Willow Dental Care #0143391675 Willow St 408-264-8700 F/T 1 (SP, TA) U

SAN LEANDRO Andy Q V Le Dds #0141551600 150ThAve 510-276-5533 P/T 1 (CA, VI) U

Smilecare-San Leandro #01414215301 Washington Ave 510-351-6820 F/T 3 P/T 5 U

SAN MATEOGeorge Wolff, DDS #014096255 N San Mateo Dr 650-347-7100 F/T 1Huyang Wu, DDS #0140951919 Ofarrell St Ste 1 650-571-6666 F/T 1Peninsula Dental #013976401 A N San Mateo Dr 650-344-7626 P/T 2SAN PABLOContra Costa Dental #01386514330 San Pablo Ave Ste B 510-234-1414 P/T 1 (Hi, Sp, Ta, Vi) U

Reach Dental Care #0137714200A Klose Way 510-223-8228 F/T 2 P/T 1 (CH, RU, SP, TA)SAN RAFAELPacific Dental Group #0135531523 5ThAve 415-453-6277 F/T 1 P/T 1 (SP, CH)San Rafael Dentistry #013447905 Lincoln Ave 415-453-1241 F/T 1 (SP)SAN RAMONCountry Fair Dental #01333412111 Alcosta Blvd 925-829-3111 F/T 2 P/T 2 (CH, HI, KO, SP) U

Perfect Smiles Fmly Dentistry #0132959260 Alcosta Blvd Ste B10 925-833-8702 P/T 1 (TA) U

San Ramon Family Dental #0132873160 Crow Canyon Rd Ste 100 925-866-8422 F/T 1 (HI, VI)Smilecare Dental Group #0132119130 Alcosta Blvd Ste A 925-803-9700 F/T 3 P/T 4 (SP)SANTA CLARAApex Family Dental #0131592797 El Camino Real 408-247-4871 F/T 1 (CH, SP, VI) U

Bruce Dental Corpation #0131391500 Los Padres Blvd Ste 101 408-244-3867 F/T 1 (SP, TA)Northern Dental #013133122 Saratoga Ave 408-556-1333 F/T 3 P/T 1 (SP, PE, TA)Paulette Sanford, DDS #013132310 N Winchester Blvd 408-241-6501 F/T 1Silicon Valley Dental #0131242975 Bowers Ave Ste 100 408-987-0530 F/T 1 (CH, FR, HI, JA, SP, VI)Star Dental #013123980 El Camino Real Ste 250 408-247-3740 F/T 2 (RU, TA, SP)Syed Dental Care, Inc #0127541150 Scott Blvd Ste A2 408-554-5855 F/T 1 (SP, AR)SANTA CRUZGayane Mooradian, DDS #012687550 Water St Ste J1 831-425-5515 F/T 1 (AM, FR, PE, SP)SANTA ROSABright Care Dental #0126531420 Guerneville Rd Ste 2 707-578-3776 F/T 1 U

Charles Aikawa, DDS #012522397 Aviation Blvd Ste L 707-579-1201 F/T 2 (SP) U

Essential Dental Care #01238755 Mission Cir Ste 103 707-568-0480 F/T 2 (FR, PE, SP)Plaza Dental #0121091017 Santa Rosa Plz 707-575-7240 F/T 1 P/T 1 (SP)Smilecare Dental Group #012105140 Stony Point Rd Ste A 707-578-3118 F/T 1 P/T 1 (SP)SARATOGAProspect Dental Care #01207519888 Prospect Rd Ste B 408-252-6000 F/T 2 (PE, FR, SP)Sahana Prasad, DDS #01203312860 Saratoga Sunnyvale Rd 408-867-1800 F/T 1 (HI, SP, TA) U

SOUTH SAN FRANCISCOGrand Mission Dental Group #011889 125 Northwood Dr Ste A 650-225-0202 F/T 2 (SP, TA)Jeanette Estipona, DDS #0118881133 El Camino Real Ste 4 650-296-6952 F/T 1 (TA)Northwood Dental Care #011568 125 Northwood Dr Ste A 650-827-9746 F/T 1 (TA)Trinity Dental Care #0115051124 Mission Rd 650-872-3030 F/T 1 (TA)Winston Manor Dental Office #011404101 Hickey Blvd Ste C 650-991-4848 F/T 1 (TA)STOCKTONAccess Dental #011118902 E Hammer Ln 209-957-9500 F/T 3 P/T 2 (CH, SP) U

Caring Dental Center #0107628014 Lower Sac Rd #B 209-478-9999 P/T 2 (HI, RU, SP) U

Kevin Thang Pham, DDS PC #0107063322 E Hammer Ln Ste H 209-475-0869 F/T 1 (SP, VI) U

Maria Theresa Oronce, DMD #0104991610 N El Dorado St Ste 4 209-462-8361 F/T 2Nu Smile Dental #010498707 E March Ln Ste 1 209-955-1800 F/T 1 (HI, SP) U

Park West Dental Group #010387 10928 Trinity Pkwy 209-474-8000 P/T 2 (SP) U

Simon Trenchuck, DDS #0103861341 W Robinhood Dr Ste C3 209-957-0765 F/T 1Smilecare Dental Group #0103835756 Pacific Ave Ste 75 209-472-1765 F/T 3 P/T 5 (SP) U

So. California Dtl Practice #01009540 S California St 209-941-0814 P/T 1 (SP, HI, CH) U


b. Either of the following:

b. — The existing non-functional restoration/bridge/denture was placed five or more years prior to its replacement, or

b. — If an existing partial denture is less than five years old, but must be replaced by a new partial denture due to the loss of a natural tooth, which cannot be replaced by adding another tooth to the existing partial denture.

13. A direct or indirect pulp cap is a benefit only on a vital permanent tooth with an open apex or a vital primary tooth.

14. With the exception of pulp caps and pulpotomies, endodontic procedures (e.g. root canal therapy, apicoectomy, retrofill, etc.) are only a benefit on a permanent tooth.

15. A therapeutic pulpotomy on a permanent tooth is limited to palliative treatment when the Contract Dentist is not performing root canal therapy.

16. Periodontal scaling and root planing are limited to five quadrants during any 12 month period.

17. Full mouth debridement (gross scale) is limited to one treatment in any 12 month period.

18. The benefit for the replacement of a missing posterior tooth (or teeth) is a removable partial denture. Coverage for the placement of a fixed partial denture (bridge) is optional except in the following cases:

— The sole tooth to be replaced in the arch is a permanent anterior tooth, provided it is not in connection with a partial denture on the same arch; or

— The new bridge would replace an existing, non-functional bridge utilizing the same abutment teeth, with no additional abutments or pontics with the exception of posterior cantilever bridges (see Limitation #12); or

— The abutment teeth are not being crowned solely for the purpose of supporting a pontic (each abutment tooth to be crowned must meet Limitation #8).

19. Relines, tissue conditioning and rebases are limited to one per denture during any 12 consecutive months.

20. Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited to:

— The replacement of extracted anterior teeth for adults during a healing period when the teeth cannot be added to an existing partial denture or

— The replacement of permanent tooth/teeth for children under 16 years of age.

21. Retained primary teeth shall be covered as primary teeth.

22. Excision of the frenum is a benefit only when it results in limited mobility of the tongue, it causes a large diastema between teeth or it interferes with a prosthetic appliance.

23. Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract Dentist to treat the child and upon prior authorization by Delta Dental, less applicable Copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis.

24. In cases of accidental injury, benefits available are described in Schedule B, Accident Injury Benefit. Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing) function, exclusive attrition and normal wear, will be covered as described in Schedules A, Description of Benefits and Copayments; and B, Limitations and Exclusions of Benefits.

25. Soft tissue management programs include, but are not limited to, periodontal pocket charting, root planing, scaling, curettage, oral hygiene instruction, periodontal maintenance and/or prophylaxis. If an Enrollee declines non-covered services within a soft tissue management program, it does not eliminate or alter the benefit for covered services.

26. A new removable partial, complete or immediate denture includes after delivery adjustments and tissue conditioning at no additional cost for the first six months after placement if the Enrollee continues to be eligible and the service is provided at the Contract Dentist’s facility where the denture was originally delivered.

27. An Optional procedure is defined as any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the limitations and exclusions of the program. The applicable charge to the Enrollee is the difference between the Contract Dentist’s “filed fees” for the Optional procedure and the “filed fees” for the covered procedure, plus any applicable Copayment for the covered procedure. Optional treatment does not apply when alternative choices are benefits. Optional procedures include:

— The use of a tooth-colored material when restoring a posterior tooth with a filling, inlay or onlay; and

— Units in a fixed partial denture (bridge) made of porcelain/ ceramic, which is not fused to and supported by underlying cast metal.

28. Porcelain crowns, porcelain fused to metal or resin with metal type crowns are not a benefit for children under 16 years of age. An allowance will be made for a resin crown. (See Limitation #27).

“Filed fees” means the Contract Dentist’s fees on file with Delta Dental. Questions regarding these fees should be directed to Delta Dental’s Customer Service department at 800-422-4234.

22 15

Hillview Dental Group #11490140739 Grimmer Blvd 510-651-1440 F/T 2 P/T 1 (SP)Rosalie S Geronimo, DMD Inc #0C84011956 Driscoll Rd 510-440-1406 F/T 1 (HI, TA, VI) U

Smilecare-Fremont #0C170139340 Fremont Blvd Dept 9532 510-739-3889 F/T 4 P/T 2 (SP) U

Star Dental #0C10015021 Mowry Ave 510-797-4900 F/T 1 (HI, SP) U

FRESNOAngels Family Dental #0C04013664 W Shaw Ave 559-277-5800 F/T 1 (AR, SP) U

Bullard Dental Group #085001323 E Bullard Ave Ste 104 559-439-9990 F/T 3First Family Dental #082801310 W Shaw Ave 559-229-8200 F/T 1 (SP)Frank Woo, DDS #0584013636 N 1St St Ste 126 559-243-1115 F/T 1 (SP)Fresno Dental Beechwood #0341923585 W Beechwood Ave Ste 102 559-432-0622 F/T 2 P/T 4 (SP) U

Fresno Dental Blackstone #0340416680 N Blackstone Ave 559-431-9111 F/T 1 P/T 5 (SP)Gallo Dental Group #0338115690 N Fresno St Ste 101 559-436-3470 F/T 1 P/T 1 (SP) U

Lauro So, DMD #0337351436 E Olive Ave 559-485-0340 F/T 1 (SP, TA)Northside Dental Practice #0336868835 N Cedar Ave 559-446-1350 F/T 2 (SP, VI)Ronald Nowell, DDS #0336855412 N Palm Ave Ste 109 559-432-0400 F/T 1 U

Sam Akande, DDS #033681 1902 E Ashlan Ave 559-228-3000 P/T 1 (SP)Sami Youssef, Dds #0336314755 E Gettysbrg Ave Ste 101 559-292-4444 P/T 2 (SP) U

Smilecare - Sunnyside #0334345657 E Kings Cyn Rd Ste 107 559-454-7900 F/T 3 P/T 6 (Sp)Smilecare-Fresno #0333662745 W Shaw Ave Ste 103 559-227-2900 F/T 3 P/T 9 (SP) U

Smilecare-Manchester Mall #0330631901 E Shields Ave Ste 226 559-226-2626 F/T 3 P/T 7 (SP) U

St George Quality Dental #0330181515 W Shaw Ave Ste 101 559-227-1700 F/T 1 P/T 1 (AM, AR, RU, SP)Tower Dental Care #0328791215 N Del Mar Ave 559-233-5625 F/T 1 (SP)White & Bright Family Dental #0328526073 N Fresno St 559-432-6384 F/T 1 (PE, SP)GALTGalt Plaza Dental #0327151067 C St Ste 125 209-744-0463 F/T 1 P/T 1 (HI, RU, SP)Sirak Workneh, DDS #032650430 Pine St 209-744-9917 P/T 1 (SP, RU, CH)GREENFIELDRafid Khamis, DDS #032638329 El Camino Real 831-674-0235 F/T 1 (SP) U

HAYWARDDental Solutions/Dr Shtulman #03233019682 Hesperian Blvd Ste 101 510-782-9942 P/T 1 (RU, SP)Fairway Park Dental Office #03227131111 Mission Blvd 510-477-6887 F/T 1 (SP, TA)Gan Dental Care #03210530512 Mission Blvd Ste 100 510-471-1500 F/T 4 P/T 1 (SP, VI) U

Kelvin Cai, DDS #0320541689 Industrial Pkwy W 510-264-9074 P/T 1 (CA, SP)

Smilecare-Hayward #03203422421 Hesperian Blvd 510-782-4161 F/T 4 P/T 4 U

HERCULESDental Center of Hercules #031953844 Willow Ave Ste A6 510-245-3004 F/T 1 (SP, TA) U

King CityJose Cardenas, DDS #031828105B Broadway St 831-386-0148 P/T 1LINCOLNCitadel Dental #031827941 Sterling Pkwy Ste 100 916-408-8585 P/T 1 (GE, PE, RU, TR)Lincoln Hills Family Dental #0315502295 Fieldstone Dr Ste 100 916-543-0222 P/T 1 U

Parkway Dental Group #031208781 Sterling Pkwy 916-543-7880 F/T 2 P/T 1 (SP) U

LIVERMORECountry Club Dental Care 031197 1046 Murrieta Blvd 925-456-7600 P/T 1 (HI, RU, SP)Livermore Dental #031123867 E Stanley Blvd 925-243-6491 F/T 1 P/T 1 (Ei, Sp)LODILodi Dental Group #031122531 W Kettleman Ln 209-366-1850 P/T 1 (SP)LOS ALTOSLos Altos Dental Spa #031062919 Fremont Ave Ste 200 650-917-9603 F/T 1 (FR, SP) U

Samson Fu-Keung Lee, DDS #031027763 Altos Oaks Dr Ste 3 650-948-6075 F/T 1 (SP)LOS GATOSLos Gatos Dental Care #031026555 Knowles Dr Ste 112 408-370-7733 F/T 1 (AR, FR, SP) U

Ronald Matsuura, DDS #030836431 Monterey Ave Ste 6 408-354-1717 F/T 1 (SP, VI)MADERANorthwest Dental Care #030822 2295 W Cleveland Ave Ste D 559-674-0927 F/T 1 MANTECAStadium Dental Group #030705 2288 Daniels St 209-456-5610 F/T 1 P/T 1 (SP) U

MARTINEZMartinez Dental #0305831160 Arnold Dr Ste G 925-372-7100 F/T 3 P/T 3 (SP, TA) U

Parkway Smiles Dental #0305231029 Arnold Dr Ste 9 925-229-8890 F/T 1 U

MENLO PARKJoseph K Sarkosh, DDS #030245888 Oak Grove Ave Ste 6 650-327-8081 P/T 1 (SP)MERCEDAccess Dental #030033 12 W 20th St 209-388-1000 F/T 3 (AM, SP) U

MILLBRAECecilia Ju, DDS #029990140 El Camino 650-259-9896 F/T 1 (CH)Dental Ease #0299891070 Broadway 650-697-3273 P/T 1 (AR, SP, TA)Pedro Caturay, DDS #0298821301 Broadway Ste 7 650-589-3667 P/T 1MILPITASKim Luu, DDS #0298371105 S Park Victoria Dr 408-263-3090 F/T 1 (SP, VI)Madhvi Desai, DDS #02983540 N Park Victoria Dr Ste D 408-263-0371 F/T 1 (SP, HI)Nisha Dharmani, DDS #029718430 E Calaveras Blvd 408-263-9714 F/T 1 (HI, SP, VI) U

Radiant Dental Care #02971510 S Hillview Dr 408-719-1643 F/T 1 (VI, SP) U

MODESTOAlan Vincent, DDS #029379105 Melrose St 209-522-0411 F/T 1Coffee Family Dental #0292691130 Coffee Rd Ste 1A 209-523-5991 P/T 2 (SP, HI)Modesto Dental #0291212225 Plaza Pkwy Ste P1 209-576-8181 F/T 2 P/T 2Pelandale Dental Care #0289783900 Pelandale Ave Ste 135 209-545-9282 P/T 1 (RU, SP, HI) U

Smilecare-Modesto #0288402900 Standiford Ave Ste 2 209-577-5008 F/T 3 P/T 2 (SP)MORGAN HILLCondit Dental #02871417020 Condit Rd Ste 180 408-778-4548 F/T 1 (VI) U

Morgan Hill Dental Care #028713154 Cochrane Plz 408-778-4838 F/T 1 P/T 1 (SP, VI) U

South Valley Dental #02841315870 Monterey St 408-778-6684 F/T 1 (SP, VI) U

MOUNTAIN VIEWAfshin Abdollahi, DDS #028290285 South Dr 650-988-0787 P/T 2 (SP)California Family Dental #0282812425 California St Ste D 650-967-1389 F/T 1 (HI, SP)Camino Family Dentistry #028184451 W El Camino Real Ste B 650-938-9002 F/T 1 (SP, TA) U

Christine Thai, DMD #0280942500 Hospital Dr Bldg 1 # 5 650-961-5070 P/T 1Donian Shen, DDS #028071105 South Dr Ste 140 650-938-1868 F/T 1 (CA, JA, SP, TA)Olive Tree Dental #0280662290 W El Camino Real Ste 3 650-938-8870 F/T 1 (TA) U

San Antonio Dental #028063530 Showers Dr Ste 3 650-917-8348 F/T 2 (CH, SP) U

NAPATrancas Dental Group #028062935 Trancas St Ste 4E 707-257-6277 F/T 4 P/T 1 (SP)NEWARKAll Smile Dental Center #02805537070 Newark Blvd Ste E 510-790-8268 P/T 1 (CA, CH, SP) U

Scott Nguyen, DDS #0279926180 Jarvis Ave Ste J 510-795-9669 F/T 1NORTH HIGHLANDSSmilecare Dental Group #0278243901 Madison Ave Ste 5 10 916-339-9000 F/T 5 P/T 6 (SP) U

OAKLANDBay Area Dental #027639 475 8th St 510-763-7400 F/T 1 U

City Center Dental Spa #027422300 F H Ogawa Plz Ste 100 510-763-6300 F/T 1 (SP) U

East Bay Family Dentistry #0271393040 E 9th St Ste D 510-534-0706 P/T 3 (SP) U

Elegant Smiles #0271273301 E 12th St Ste 165 510-533-5500 F/T 1 P/T 3 (SP) U

Family Dentists #0269931510 Franklin St 510-893-1923 F/T 1 (SP)Franklin Dental Care #0269331624 Franklin St Ste 1220 510-893-4041 F/T 1 P/T 1 (KO, SP) U

Oakland Dental #0268608105 Edgewater Dr 510-568-6272 F/T 2 P/T 3 (SP)Oakland Dental Care #0265771700 Broadway 510-444-6300 F/T 1 (SP)Timothy Han, DDS #026559320 13th St Ste 301 510-839-2045 P/T 1 (KO)

Timothy Han, DDS #0265252710 Telegraph Ave Ste 250 510-839-4106 P/T 1 (KO, TA)PALO ALTOPalo Alto Dental Care #0265053737 El Camino Real 650-858-2028 F/T 2 P/T 1 (CA, CH, HI, RU, SP) U

PARLIERDiljeet Heer, DDS #026471545 E Manning Ave Ste 108 559-646-3844 F/T 1 (SP, HI) U

PETALUMAMichael Haglund, DDS #026261765 Baywood Dr Ste 101 707-762-5561 F/T 1 U

Petaluma Dental Care #0261871436 Professional Dr Ste 302 707-763-2828 P/T 1 (SP, FR, PE)Petaluma Family Dental Care #02618135 Maria Dr Ste 854 707-763-3203 F/T 1 P/T 1Premier Dental Care #026176229 N Mcdowell Blvd 707-766-7373 F/T 1 (FR, GE, SP) U

Surya Manga Achyuta, DDS #0260821372 N Mcdowell Blvd Ste B1 707-778-9993 F/T 1 P/T 1 (HI, PE, TA) U

PINOLEPinole Dental #0260811477 Fitzgerald Dr Ste 106 510-669-0350 F/T 4 P/T 1PITTSBURGSky Dental #0260382230 Gladstone Dr Ste 100 925-432-2444 F/T 2 P/T 1 (PE, SP, TA) U

PLACERVILLEBrookside Dental #0260364330 Golden Center Dr 530-622-1987 F/T 1 U

Placerville Dental & Ortho #026025699 Main St Ste B 530-295-8000 F/T 1 U

PLEASANT HILLDiablo Valley Dental Care #02587630 Golf Club Rd Ste C 925-685-8633 F/T 1 P/T 2 (CH, SP) U

PLEASANTONAlisal Dental Care #0258745933 Coronado Ln Ste 2F 925-846-6308 F/T 2Bay Family Dental Care #025873173 Spring St Ste 110 925-600-9006 P/T 1 (PE)Bernal Dental Group #0257104466 Black Ave Ste K 925-485-1172 F/T 1 P/T 1 (CH, HI)Tri-Valley Dental #0256815820 Stnrge Mall Rd Ste 118 925-225-1555 F/T 1 (KO, SP, TA)RANCHO CORDOVARancho Cordova Dental Group #02567910390 Coloma Rd Ste A 916-368-0440 P/T 1 (KO, CH, RU) U

River City Dental Group #02567810910 Olson Dr Ste 100 916-638-3780 F/T 1 P/T 1 U

St Mary Family Dental Office #02556811050 Coloma Rd Ste 17 916-635-9800 F/T 1 (SP) U

REDDINGAccess Dental #0255672147 Court St 530-246-4100 U

Access Dental #0254701667 Hilltop Dr 530-223-5500 F/T 2 U

REDWOOD CITYBay Area Dental Office #02546929 Birch St Ste 3 650-587-3788 F/T 1Birch Dental Group #025284155 Birch St Ste 5 650-366-0552 P/T 1Eugene Espiritu #025253705 Veterans Blvd Ste Suite1 650-298-8818 P/T 1 (TA, CA, CH, SP)Laluces Dental #0252462480 El Camino Real 650-216-8488 F/T 1United Dental #025083647 Veterans Blvd 650-367-4300 P/T 1 U

RICHMONDWinning Smile Dental Group #02508012732 San Pablo Ave 510-233-3100 F/T 1ROCKLINHealthy Smiles Family Dntstry #0250352160 Sunset Blvd Ste 503 916-771-0757 F/T 1 (CA) U

Highland Dental Grp #0248943291 Stanford Ranch Rd # 102 916-435-1665 P/T 2Martin Kerzie, DMD #0248554970 Rocklin Rd Ste 100 916-626-5525 F/T 2Smile Time Dental #0248506000 Fairway Dr Ste 8 916-632-0404 F/T 1 P/T 2ROHNERT PARKLora H Costa, DDS #0246911331 Medical Center Dr Ste H 707-585-8599 P/T 1 (TA, SP, VI) U

Rohnert Park Dental #0246525755 Redwood Dr 707-584-1000 F/T 2 P/T 2 U

ROSEVILLEAesthetic Dentistry #0244458445 Sierra College Blvd # B 916-773-0505 F/T 1 (AM, RU) U

American Family Dentistry #0244441160 Cirby Way #100 916-789-8530 F/T 2 (PE, RU, SP) U

Healthy Image Dental Group #024315576 N Sunrise Ave Ste 140 916-786-6431 F/T 2 P/T 1 (VI) U

Healthy Impressions Dental #024308730 Sunrise Ave Ste 120 916-797-0868 P/T 1Hetal Rana, DDS #0242761422 Blue Oaks Blvd Ste 130 916-774-4499 F/T 1 (HI) U

Interdental Care #024221106 N Sunrise Ave Ste B10 916-787-0631 F/T 1 (SP, RU, TA, CH, VI) U

Pavilions Dental Group #0240221259 Plsnt Grv Blvd Ste 100 916-782-2010 F/T 1 P/T 1 (SP)Pleasant Grove Dental Group #02402110357 Fairway Dr Ste 100 916-782-4500 P/T 2 U

River City Dental Group #0240201079 Sunrise Ave Ste C 916-784-3101 P/T 1 (SP) U

Rocky Ridge Family Dental #0240191700 Rocky Ridge Dr Ste 100 916-782-6001 P/T 1 U

Roseville Dental! #023862960 Sunrise Ave Ste 115 916-772-9300 P/T 4Said Shaari, DDS #023836406 1/2 Sunrise Ave Ste 270 916-789-4568 P/T 1 (FR) U

Shailesh Jawale, DDS #023833928 Plsnt Grv Blvd Ste 100 916-772-1367 F/T 1Siamak Okhovat, DDS #0236932110 Professional Dr Ste 115 916-783-5600 F/T 1 (GE, PE) U

Star Dental #0236892030 Douglas Blvd Ste 37 916-773-6222 F/T 2 (PE, SP) U

SACRAMENTOArden Oaks Dental Care #0236881741 Professional Dr 916-485-5539 F/T 1 U

Brent Varshawsky, DMD #0236871901 Watt Ave Ste 2 916-483-5677 F/T 1Brian C Steele, DDS #0236651115 12th St # 2A 916-443-4430 P/T 1 (SP) U

Charles Tran, DDS #0236526175 Stockton Blvd Ste 260 916-427-6263 F/T 1 (CH, SP, VI) U

De La Osa DDS Inc #0236157315 Stockton Blvd Ste 3 916-422-8332 F/T 1 (SP)Elder Creek Dental #0235804730 47th Ave 916-391-0682 F/T 1 (KO, VI)Greenhaven Dental Group #023542925 Secret River Dr Ste B 916-421-3993 F/T 1 P/T 1


15. Appliances or restorations necessary to increase vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings, equilibration or treatment of disturbances of the temporomandibular joint (TMJ).

16. An initial treatment plan which involves the removal and reestablishment of the occlusal contacts of 10 or more teeth with crowns, onlays, fixed partial dentures (bridges), or any combination of these is considered to be full mouth reconstruction under the DeltaCare USA program. Crowns, onlays and fixed partial dentures associated with such a treatment plan are not covered Benefits. This exclusion does not eliminate the benefit for other covered services.

17. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures.

18. Extraction of teeth, when teeth are asymptomatic/non-pathologic (no signs or symptoms of pathology or infection), including but not limited to the removal of third molars and orthodontic extractions.

19. Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent.

EXCLUSIONS OF BENEFITS1. Any procedure that is not specifically listed under Schedule A,

Description of Benefits and Copayments.

2. Dental conditions arising out of and due to Enrollee’s employment for which Workers’ Compensation is paid. Services which are provided to the Enrollee by state government or agency thereof, or are provided without cost to the Enrollee by any municipality, county or other subdivision, except as provided in Section 1373(a) of the California Health and Safety Code.

3. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility.

4. Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges).

5. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage.

6. Dental expenses incurred in connection with any dental procedure started before the Enrollee’s eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, orthodontics.

7. Congenital malformations (e.g. congenitally missing teeth, supernumerary teeth, enamel and dentinal dysplasias, etc.), except for the treatment of newborn children with congenital defects or birth abnormalities.

8. Dispensing of drugs not normally utilized in the delivery of dental services.

9. Any procedure that in the professional opinion of the Contract Dentist:

a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/ or surrounding structures, or

b. is inconsistent with generally accepted standards for dentistry.

10. Dental services received from any dental facility other than the assigned Contract Dentist including the services of a dental specialist, unless expressly authorized in writing by Delta Dental or as cited under Emergency Services. To obtain written authorization, the Enrollee should call Delta Dental’s Customer Service department at 800-422-4234.

11. Consultations for non-covered benefits.

12. Implant placement or removal, appliances placed on or services associated with implants, including but not limited to prophylaxis and periodontal treatment.

13. Fixed partial dentures (bridges) for children under 16 years of age.

14. Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformation of teeth.

Foreign languages spoken in The dental offices are listed by code in ( ).Below is a key to the foreign language codes:

16 21

ALBANYShadan Jabali, DDS #3C13011113 Garfield Ave 510-525-6100 F/T 1 (PE, SP)University Dental #3C1101847 San Pablo Ave 510-528-7216 P/T 2 (SP)ANTELOPEWalerga Dental Group #3C09018008 Walerga Rd Ste 100 916-725-4530 P/T 1 (SP) U

ANTIOCHAll Smile Dental Care #3983015117 Lone Tree Way 925-777-9898 F/T 1 (SP, TA, CH, VI) U

Crossings Dental Care #3982013379 Deer Valley Rd 925-706-0775 P/T 1 (SP, TA) U

Dental Care of Antioch #3977013432 Hillcrest Ave Ste 250 925-754-2145 F/T 1 U

East Bay Dental #3923015157 Lone Tree Way 925-777-1719 F/T 1 P/T 1 (HI, SP) U

Salam Ghannam, DDS #3870012225 Buchanan Rd Ste A 925-779-1112 P/T 1 Ar, Sp)AUBURNAuburn Dental Care #37860170 College Way 530-889-2828 F/T 2 U

Sierra Family Dental #3528011300 Lincoln Way Ste D 530-885-1931 F/T 1 (TA)Sierra Smiles Dental Group #3496012503 Bell Rd 530-823-3803 F/T 1 (SP) U

BELMONTBelmont Dental #336601570 Masonic Way 650-593-5110 F/T 2 P/T 4Belmont Plaza Dental Care #334601390 El Camino Real Ste D 650-631-2893 F/T 1 (RU)Peninsula Specialty Dtl Care #322201562 Ralston Ave 650-654-1854 F/T 1 (PE, SP, TA)BERKELEYBerkeley Hills Dental Group #3221012320 Woolsey St Ste 312 510-848-8624 F/T 1 P/T 1 (SP, PE, CA, TA, TR) U

Dr. Yu Family Dental Care Inc #3192013031 Telegraph Ave Ste 136A 510-845-2240 P/T 1 (CH, CA)

Henry Yang, DDS #2C99013000 Colby St Ste 302 510-843-4450 F/T 1BRENTWOODPerfect Smiles Family Dntstry #2C83014510 Ohara Ave Ste C 925-634-9118 P/T 1 (TA)Valora Legaspi, DDS #2C66012400 Balfour Rd Ste 301 925-240-5808 F/T 1 P/T 1 (SP) U

BURLINGAMEMasha Mekhteys, DDS #2C62011860 El Camino Real Ste 315 650-692-0555 F/T 1 (RU)CAMPBELLBrite Dental #2C5101281 E Hamilton Ave Ste 2 408-871-9734 P/T 1 (RO, SP, VI)CARMICHAELAccess Dental #2C38017141 Fair Oaks Blvd 916-488-9700 F/T 2 P/T 2 (RU, SP)Carmichael Oaks Dental Care #2C31018329 Fair Oaks Blvd Ste D 916-944-4739 (SP)Healing Impressions Dtl Grp #2C23018329 Fair Oaks Blvd Ste B 916-944-4782 F/T 1 (AR, RU, VI) U

Sacramento Dental Group #2C00016611 Coyle Ave 916-965-6250 P/T 1 (AM, RU)CHICOAccess Dental #2859011010 Mangrove Ave # A B 530-342-7500 F/T 4 (SP) U

Chico Dental Group #277501955 East Ave 530-893-5334 F/T 1Lakeview Dental Office #2771012571 Cal Park Dr Ste 120 530-345-6888 F/T 1 (CH) U

Smile Makers #2758012647 Forest Ave 530-879-1888 F/T 1 P/T 1 (CH, TA, IT, VI, SP)CITRUS HEIGHTSAura Dental Care #2655016024 San Juan Ave Ste A 916-729-5849 F/T 1 (HI) U

Citrus Dental Group #2429015899 Sunrise Blvd 916-967-7766 P/T 1 U

Citrus Heights Dental Office #2339016994 Sunrise Blvd 916-723-8900 F/T 1 P/T 1 (RU, SP) U

Cross Dental #2281015414 Sunrise Blvd Ste C 916-967-9953 F/T 1 (KO, PE, RU) U

Everlast Professional Dental #2266017861 Greenback Ln 916-726-1819 F/T 1 (RU, VI)

First Dental #2135016191 Greenback Ln Ste A 916-723-5330 F/T 1 U

Madison Square Dental Care #2127016024 San Juan Ave Ste C 916-728-2888 F/T 1 P/T 2 (CA, CH) U

Smilecare Dental Group #1C97016406 Acd Sunrise Blvd 916-727-1880 F/T 5 P/T 4 (SP) U

CLOVISClovis Dental! #1C93011420 Shaw Ave Ste 101 559-299-9008 F/T 2 P/T 5 (SP)Clovis Gentle Dental #1C92013151 Willow Ave 559-299-9556 F/T 2 (SP, CH, VI) U

Dental Group of Clovis #1C3701200 W Shaw Ave Ste 110 559-325-6161 F/T 1 P/T 1Smilecare - Clovis #1C23011010 Shaw Ave Ste B 559-323-1776 F/T 3 P/T 5 (SP) U

CONCORDConcord Dental Arts #1C1301 2222 East St Ste 270 925-689-3500 P/T 1 (PE) U

Dental Center at Sears #1C10011001 Sunvalley Blvd 925-682-3929 F/T 1 (HI, SP, TA)Dental Specialty Group #1968011255 Willow Pass Rd 925-680-4444 F/T 2 (PE, VI)Lester Yamashita, DDS #1955012969 Salvio St 925-685-5296 F/T 1 (JA, SP)Smilecare Dental Group #1916011851 Sutter St 925-827-2798 F/T 3 P/T 6 (SP) U

CORCORANJohn Richardson, DDS #1864011409 Whitley Ave Ste D 559-992-4138 F/T 1 (SP)CUPERTINOI Pro Dental #18560119705 Stevens Creek Blvd 408-996-7987 F/T 1 (CH, SP) U

DALY CITYBella Lim, DDS #1846017455 El Camino Real Ste C 650-994-4561 F/T 1Campus Heights Dental #183701901 Campus Dr Ste 304 650-756-1900 P/T 1Jayson Lo, DMD #178901341 Westlake Ctr Ste 301 650-755-7722 F/T 1Jesus Odulio DMD Corporation #178801347 Gellert Blvd Ste K 650-757-5379 F/T 1 (SP, TA) U

Mouhannad Al- Majdalani, DDS #178701320 Washington St Apt 105 650-994-111 P/T 1 (AR, CH, SP, TA)Rodolfo Villasin, DMD #178501341 Westlake Ctr Ste 237 650-756-6211 F/T 1 (TA) U

Valderrama Dental Corp #177701343 Gellert Blvd Ste G 650-757-1749 F/T 1 (PE, SP, TA) U

DAVISTwin Pines Dental #1675011109 Kennedy Pl Ste 4 530-753-9900 F/T 1 (SP)DUBLINLeida P Stine DDS Inc #1656017950 Dublin Blvd Ste 101 925-828-9993 F/T 1 (AR, TA, VI)Restore Smiles Dental #1653016990 Village Pkwy Ste 210 925-556-9074 F/T 1 (Hi, Ta) U

View Mobile Dental #1644017040 Dublin Blvd 925-225-9552 F/T 1 (TA)EL CERRITOArt Dental #16420110586 San Pablo Ave 510-559-8598 P/T 1 (CH, SP, VI) U

Rodney Kim, DDS #16330111100 San Pablo Ave Ste 107 510-233-9022 F/T 1 U

EL DORADO HILLSGreen Valley Dental Group #1577012205 Francisco Dr Ste 150 916-934-0207 P/T 2ELK GROVEAlpha Dental #1550018239 Laguna Blvd Ste 100 916-683-9080 P/T 1 (SP) U

Cozy Dental #1545012370 Maritime Dr 916-683-2272 F/T 4 (RU, SP)Elk Grove Dental Group #1517019640 Bruceville Rd Ste 101 916-686-9030 P/T 2 (SP) U

Elk Grove Landing Fmly Dtl #1501018351 Elk Grove Blvd Ste 300 916-691-6997 P/T 1 U

Smilecare-Elk Grove #1465019184 E Stockton Blvd 916-686-1101 F/T 2 P/T 7 (SP) U

VP Dental Care #1441019320 Elk Grove Blvd Ste 170 916-714-5422 P/T 1 U

EUREKAJames Foye, DMD #1436012805 G St 707-443-6392 F/T 1FAIR OAKSRiver City Dental Group #1433018908 Madison Ave 916-536-5151 P/T 1

FAIRFIELDAccess Dental #1426011600 Travis Blvd 707-429-4000 F/T 5 P/T 2 (SP) U

Dental Health Care #1424011555 Webster St Ste B 707-435-1906 P/T 1Dr Richard Ramos, DMD Inc #1421013075 Travis Blvd 707-435-9004 F/T 1 (TA) U

Julius Mosley II, DDS #1383012750 N Texas St Ste 340 707-421-2161 F/T 1 (TA) U

Smilecare-Fairfield #1375011955 W Texas St 707-428-5400 F/T 1 P/T 8 (SP) U

FOLSOMCosmetic Dental Studios #1374012700 E Bidwell St Ste 300 916-984-5552 F/T 1 (GE, PE, TR) U

Gateway Dental Group #1372012465 Iron Point Rd Ste 120 916-984-9600 P/T 2 (SP) U

Smile Time Dental #1365011568 Creekside Dr Ste 201 916-984-4224 F/T 5 (PE, RU, SP, TA) U

Smilecare-Folsom #136201825 E Bidwell St Ste 400 916-984-4591 F/T 4 P/T 6 (SP) U

FOSTER CITYJing-Jing Qian, DDS #1355011289 E Hillsdale Blvd Ste 3 650-572-8518 F/T 1 (CH)FREMONTAarisha Dental Office #13490143625 Mission Blvd Ste 105 510-656-7424 F/T 1 (HI, SP, TA)Advanced Smile Design #13470139560 Stevenson Pl Ste 117 510-797-8100 F/T 1 (HI, TA) U

American Dental Group #13300139624 Mission Blvd 510-744-1177 F/T 2 Brookevale Family Dentistry #13280139236 Argonaut Way 510-739-0701 F/T 2 P/T 2 (SP, VI) U

Dental Care Center #13240139470 Fremont Blvd 510-745-9222 F/T 1 (PE, SP, CH, HI)Duc Nguyen, DDS #12710139411 Fremont Blvd 510-438-9201 F/T 1Esquire Dental #12180137259 Fremont Blvd 510-790-0700 F/T 1Fremont Hills Dental Office #115101698 Mowry Ave 510-608-6097 F/T 1 (TA) U

Additional dental offices will be added as required. If any office is closed to further enrollment, Delta Dental reserves the right to assign you another dental office as close to your home as possible. All members of your family must be treated at the same facility.

LANGUAGE ASSISTANCE: Language capabilities are self-reported by the individual dental facilities and not independently verified by Delta Dental. If an enrollee requires language assistance to enable communication in a dental setting, Delta Dental will arrange for professional services through a certified interpretation vendor at no cost to the enrollee.

ATENCIÓN EN OTROS IDIOMAS: Las habilidades en idiomas son informadas por las instalaciones dentales individuales y no son verificadas independientemente por Delta Dental. Si un afiliado requiere ayuda en otro idioma para poder comunicarse durante la cita dental, Delta Dental coordinará los servicios profesionales mediante un proveedor certificado de interpretación sin costo para el afiliado.

Northern California Offices (Open)

DeltaCare USA Participating Dental OfficesPlease indicate the number of the office you have selected on the DeltaCare USA enrollment form.


ORTHODONTIC LIMITATIONSThe DeltaCare USA program provides coverage for orthodontic treatment plans provided through Contract Orthodontists. The start-up fees and the cost to the Enrollee for the treatment plan are listed in Schedule A, Description of Benefits and Copayments and subject to the following:

1. Orthodontic treatment must be provided by a Contract Orthodontist.

2. Benefits cover 24 months of active comprehensive orthodontic treatment. Included is the initial examination, diagnosis, consultation, initial banding, 24 months of active treatment, de-banding and the retention phase of treatment. The retention phase includes the initial construction, placement and adjustment to retainers and office visits for a maximum of two years.

3. Treatment plans extending beyond 24 months of active treatment, or 24 months of the retention phase of treatment will be subject to a monthly office visit fee to the Enrollee not to exceed $75.00 per month.

4. Should an Enrollee’s coverage be cancelled or terminated for any reason, and at the time of cancellation or termination be receiving any orthodontic treatment, the Enrollee and not Delta Dental will be responsible for payment of any balance due for treatment provided after cancellation or termination. In such a case the Enrollee’s payment shall be based on a maximum of $2,300.00 for covered dependent children to age 19 and $2,500.00 for covered adults and dependent adult children age 19 and older. The amount will be prorated over the number of months to completion of the treatment and, will be payable by the Enrollee on such terms and conditions as are arranged between the Enrollee and the Contract Orthodontist.

5. If treatment is not required or the Enrollee chooses not to start treatment after the diagnosis and consultation has been completed by the Contract Orthodontist, the Enrollee will be charged a consultation fee of $25.00 in addition to diagnostic record fees.

6. Three recementations or replacements of a bracket/band on the same tooth or a total of five rebracketings/rebandings on different teeth during the covered course of treatment are benefits. If any additional recementations or replacements of brackets/bands are performed, the Enrollee is responsible for the cost at the Contract Orthodontist’s “filed fees.”

7. Comprehensive orthodontic treatment (Phase II) consists of repositioning all or nearly all of the permanent teeth in an effort to make the Enrollee’s occlusion as ideal as possible. This treatment usually requires complete fixed appliances; however, when the Contract Orthodontist deems it suitable, a European or removable appliance therapy may be substituted at the same Copayment amounts as for fixed appliances.

8. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.

“Filed fees” means the Contract Orthodontist’s fees on file with Delta Dental. Questions regarding these fees should be directed to Delta Dental’s Customer Service department at 800-422-4234.

F/T – Number of full-time dentistsP/T – Number of part-time dentists

AF – AfrikaansAR – ArabicAM – ArmenianCA – CantoneseCH – ChineseCL – CreoleCS – CzechEI – East IndianFR – FrenchGE – German

GR – GreekHE – HebrewHI – HindiHR – CroatianHU – HungarianIN – IndonesianIT – ItalianJA – JapaneseKO – KoreanPE – Persian

PL – PolishRO – RomanianRU – RussianSP – Spanish/EspañolTA – TagalogTH – ThaiTR – TurkishVI – Vietnamese

Please call 800-422-4234 for updates to this list or check our online Dentist Directory at: www.deltadentalins.com/deltacareusa.

17

ORTHODONTIC EXCLUSIONS1. Pre-, mid- and post-treatment records which include

cephalometric x-rays, tracings, photographs and study models.

2. Lost, stolen or broken orthodontic appliances.

3. Retreatment of orthodontic cases.

4. Changes in treatment necessitated by accident of any kind, and/or lack of Enrollee cooperation.

5. Surgical procedures incidental to orthodontic treatment.

6. Myofunctional therapy.

7. Surgical procedures related to cleft palate, micrognathia or macrognathia.

8. Treatment related to temporomandibular joint disturbances.

9. Supplemental appliances not routinely used in typical comprehensive orthodontics.

10. Restorative work caused by orthodontic treatment.

11. Phase I orthodontics, as well as activator appliances and minor treatment for tooth guidance and/or arch expansion. Phase I orthodontics is defined as early treatment including interceptive orthodontia prior to the development of late mixed dentition.

12. Extractions solely for the purpose of orthodontics.

13. Transfer after banding has been initiated.

14. Composite bands, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.

ACCIDENT INJURY BENEFITAn accidental injury is damage to the hard and soft tissue of the mouth caused directly and independently of all other causes by external forces. Damage to the hard and soft tissue of the mouth from normal chewing function is covered under Schedule A, Description of Benefits and Copayments.

Delta Dental will pay up to 100 percent of the Contract Dentist’s “filed fees,” for expenses an Enrollee incurs for an accident injury, less any applicable Copayment(s), up to a Maximum of $1,600.00 in any 12 month period.

Accident injury benefits include the following procedure in addition to those listed in Schedule A, Description of Benefits and Copayments.

CODE D7270 Tooth reimplantation and/or stabilization of accidentally

evulsed or displaced tooth and/or alveolus — includes splinting and/or stabilization.

Payment of accident injury benefits is subject to Schedule B, Limitations and Exclusions of Benefits, in addition to the following provisions:

MAXIMUM Accident injury benefits will be provided for each Enrollee up to a maximum of $1,600.00 in any 12 month period.

LIMITATION Accident injury benefits are limited to services provided as a result of an accident which occurred (a) while the Enrollee was covered under the DeltaCare USA program, or (b) while the Enrollee was covered under another DeltaCare USA program, and if the benefits for the expenses incurred would have been paid if the Enrollee had remained covered under that program.

EXCLUSIONS In addition to Schedule B, limitations #13, #15, #20, #21, #24 and #28 and exclusions #1-9, #11-15, #18 and #19, the following exclusions apply:

1. Prophylaxis.

2. Extra-oral grafts (grafting of tissues from outside the mouth to oral tissue).

3. Replacement of existing restorations due to decay.

4. Orthodontic services (treatment of malalignment of teeth and/or jaws).

5. Replacement of existing restorations, crowns, bridges, dentures and other dental or orthodontic appliances damaged by accident injury.


18 19

n How to enroll in DeltaCare USA

Complete the enrollment form on page 19. If you are already a Kaiser Permanente member, please include a copy of your Kaiser Permanente ID card. If you are not yet a Kaiser Permanente member, please include a copy of your Medical Enrollment Form (Form SF 2809). You must be a Federal member of Kaiser Permanente to enroll.

Please select one of the following payment methods on the attached enrollment form. The two payment methods are explained below.

n Monthly payment via automatic deduction

1) Complete and sign the Automatic Payment Authorization section on the enrollment form. Be sure to enclose a voided blank check from this account. Also, please call your bank to obtain the ABA number (bank routing number).

2) Your Monthly Dues will be deducted from the account specified on the 15th of each month prior to the coverage month (e.g., April dues will be deducted on March 15th). Your coverage will automatically be terminated if your automatic deduction is declined by your bank for insufficient funds, a closed account, etc.

3) Return the enrollment materials by December 21, 2010 if you are enrolling during the open enrollment period to:

Kaiser Permanente Federal Employees Dental Program Delta Dental 17871 Park Plaza Drive, Suite 200 Cerritos, CA 90703

n Quarterly payment via check

1) Submit the first quarterly payment with your enrollment form. Once enrolled, you will be billed quarterly (i.e., every three months) thereafter. Dues must be paid in full by the 15th of the month prior to the coverage month or your coverage will be automatically terminated. You cannot have a break in coverage.

2) Return the enrollment form and the first quarterly payment (see quarterly rates on the enrollment form) by December 21, 2010 if you are enrolling during the open enrollment period to:

Kaiser Permanente Federal Employees Dental Program Delta Dental Dept. #0170 Los Angeles, CA 90084-0170

Note: If you are a new federal employee or enrolling outside of the open enrollment period, the enrollment information must be received at the latest by the 15th of the month for coverage to begin the 1st of the following month. Incomplete/inaccurate information will cause a delay in your enrollment into the program.

Your full name Social Security # — —

Kaiser Permanente Medical Record #

Mailing address City State ZIP

Phone number ( ) — Date of birth / / Male Female

Type of Enrollment One person Two persons Three or more persons Marital status: Single Married








Payment Option Monthly (Automatic) Quarterly (Payment by check)

Automatic payment authorizationI (we) hereby authorize Delta Dental to charge the applicable Monthly Dues for dental coverage to my account designated below. I understand that coverage will only become and remain effective if there are sufficient funds at the time of the deduction. I understand eligibility begins the first of the month following my initial deduction. This authority to deduct funds from my account is to remain in full force and effect until I notify Delta Dental in writing 30 Days prior to termination. I also understand there cannot be any lapse of coverage in a 12-month period from the time of my enrollment. I agree to comply with the terms as outlined in the Combined Evidence of Coverage and disclosure Form. (My bank is authorized to make corrections if any should be necessary.)

Checking Account Savings Account (Please enclose a voided check or preprinted deposit slip from the account checked.)

Bank or savings and loan name

Branch________________________________________________________ Branch telephone number ( ) —

City, State ZIP code __________________

ABA (bank routing #) Account number_________________________________________________

Signature of enrollee Signature of spouse

Notice: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any

false, incomplete, or misleading information may be guilty of a felony of the third degree.(rev. 9/08)

DeltaCare USA + This is a dental HMO program. You and your family must receive all treatment from

the DeltaCare USA Dental office you select. Please indicate the number of the DeltaCare USA office you have chosen: #_____________________________ If you do not select an office, we will select one for you.

Rates for Calendar Year 2011:

Enrollment type Monthly (automatic deduction) Quarterly (Payment by check)

One person $ 11.89 $ 35.67

Two persons $ 19.90 $ 59.70

Three persons or more $ 30.17 $ 90.51

Kaiser Permanente Federal Employees Dental ProgramDelta DentalDept. #0170Los Angeles, CA 90084-0170

Enrollment Form: Kaiser Permanente Federal Member Dental Program

PLEASE PRINT

(verify account information with your bank)

EN

RO

LL

ME

NT

FO

RM

Foreign languages spoken in The dental offices are listed by code in ( ).Below is a key to the foreign language codes:

16 21

ALBANYShadan Jabali, DDS #3C13011113 Garfield Ave 510-525-6100 F/T 1 (PE, SP)University Dental #3C1101847 San Pablo Ave 510-528-7216 P/T 2 (SP)ANTELOPEWalerga Dental Group #3C09018008 Walerga Rd Ste 100 916-725-4530 P/T 1 (SP) U

ANTIOCHAll Smile Dental Care #3983015117 Lone Tree Way 925-777-9898 F/T 1 (SP, TA, CH, VI) U

Crossings Dental Care #3982013379 Deer Valley Rd 925-706-0775 P/T 1 (SP, TA) U

Dental Care of Antioch #3977013432 Hillcrest Ave Ste 250 925-754-2145 F/T 1 U

East Bay Dental #3923015157 Lone Tree Way 925-777-1719 F/T 1 P/T 1 (HI, SP) U

Salam Ghannam, DDS #3870012225 Buchanan Rd Ste A 925-779-1112 P/T 1 Ar, Sp)AUBURNAuburn Dental Care #37860170 College Way 530-889-2828 F/T 2 U

Sierra Family Dental #3528011300 Lincoln Way Ste D 530-885-1931 F/T 1 (TA)Sierra Smiles Dental Group #3496012503 Bell Rd 530-823-3803 F/T 1 (SP) U

BELMONTBelmont Dental #336601570 Masonic Way 650-593-5110 F/T 2 P/T 4Belmont Plaza Dental Care #334601390 El Camino Real Ste D 650-631-2893 F/T 1 (RU)Peninsula Specialty Dtl Care #322201562 Ralston Ave 650-654-1854 F/T 1 (PE, SP, TA)BERKELEYBerkeley Hills Dental Group #3221012320 Woolsey St Ste 312 510-848-8624 F/T 1 P/T 1 (SP, PE, CA, TA, TR) U

Dr. Yu Family Dental Care Inc #3192013031 Telegraph Ave Ste 136A 510-845-2240 P/T 1 (CH, CA)

Henry Yang, DDS #2C99013000 Colby St Ste 302 510-843-4450 F/T 1BRENTWOODPerfect Smiles Family Dntstry #2C83014510 Ohara Ave Ste C 925-634-9118 P/T 1 (TA)Valora Legaspi, DDS #2C66012400 Balfour Rd Ste 301 925-240-5808 F/T 1 P/T 1 (SP) U

BURLINGAMEMasha Mekhteys, DDS #2C62011860 El Camino Real Ste 315 650-692-0555 F/T 1 (RU)CAMPBELLBrite Dental #2C5101281 E Hamilton Ave Ste 2 408-871-9734 P/T 1 (RO, SP, VI)CARMICHAELAccess Dental #2C38017141 Fair Oaks Blvd 916-488-9700 F/T 2 P/T 2 (RU, SP)Carmichael Oaks Dental Care #2C31018329 Fair Oaks Blvd Ste D 916-944-4739 (SP)Healing Impressions Dtl Grp #2C23018329 Fair Oaks Blvd Ste B 916-944-4782 F/T 1 (AR, RU, VI) U

Sacramento Dental Group #2C00016611 Coyle Ave 916-965-6250 P/T 1 (AM, RU)CHICOAccess Dental #2859011010 Mangrove Ave # A B 530-342-7500 F/T 4 (SP) U

Chico Dental Group #277501955 East Ave 530-893-5334 F/T 1Lakeview Dental Office #2771012571 Cal Park Dr Ste 120 530-345-6888 F/T 1 (CH) U

Smile Makers #2758012647 Forest Ave 530-879-1888 F/T 1 P/T 1 (CH, TA, IT, VI, SP)CITRUS HEIGHTSAura Dental Care #2655016024 San Juan Ave Ste A 916-729-5849 F/T 1 (HI) U

Citrus Dental Group #2429015899 Sunrise Blvd 916-967-7766 P/T 1 U

Citrus Heights Dental Office #2339016994 Sunrise Blvd 916-723-8900 F/T 1 P/T 1 (RU, SP) U

Cross Dental #2281015414 Sunrise Blvd Ste C 916-967-9953 F/T 1 (KO, PE, RU) U

Everlast Professional Dental #2266017861 Greenback Ln 916-726-1819 F/T 1 (RU, VI)

First Dental #2135016191 Greenback Ln Ste A 916-723-5330 F/T 1 U

Madison Square Dental Care #2127016024 San Juan Ave Ste C 916-728-2888 F/T 1 P/T 2 (CA, CH) U

Smilecare Dental Group #1C97016406 Acd Sunrise Blvd 916-727-1880 F/T 5 P/T 4 (SP) U

CLOVISClovis Dental! #1C93011420 Shaw Ave Ste 101 559-299-9008 F/T 2 P/T 5 (SP)Clovis Gentle Dental #1C92013151 Willow Ave 559-299-9556 F/T 2 (SP, CH, VI) U

Dental Group of Clovis #1C3701200 W Shaw Ave Ste 110 559-325-6161 F/T 1 P/T 1Smilecare - Clovis #1C23011010 Shaw Ave Ste B 559-323-1776 F/T 3 P/T 5 (SP) U

CONCORDConcord Dental Arts #1C1301 2222 East St Ste 270 925-689-3500 P/T 1 (PE) U

Dental Center at Sears #1C10011001 Sunvalley Blvd 925-682-3929 F/T 1 (HI, SP, TA)Dental Specialty Group #1968011255 Willow Pass Rd 925-680-4444 F/T 2 (PE, VI)Lester Yamashita, DDS #1955012969 Salvio St 925-685-5296 F/T 1 (JA, SP)Smilecare Dental Group #1916011851 Sutter St 925-827-2798 F/T 3 P/T 6 (SP) U

CORCORANJohn Richardson, DDS #1864011409 Whitley Ave Ste D 559-992-4138 F/T 1 (SP)CUPERTINOI Pro Dental #18560119705 Stevens Creek Blvd 408-996-7987 F/T 1 (CH, SP) U

DALY CITYBella Lim, DDS #1846017455 El Camino Real Ste C 650-994-4561 F/T 1Campus Heights Dental #183701901 Campus Dr Ste 304 650-756-1900 P/T 1Jayson Lo, DMD #178901341 Westlake Ctr Ste 301 650-755-7722 F/T 1Jesus Odulio DMD Corporation #178801347 Gellert Blvd Ste K 650-757-5379 F/T 1 (SP, TA) U

Mouhannad Al- Majdalani, DDS #178701320 Washington St Apt 105 650-994-111 P/T 1 (AR, CH, SP, TA)Rodolfo Villasin, DMD #178501341 Westlake Ctr Ste 237 650-756-6211 F/T 1 (TA) U

Valderrama Dental Corp #177701343 Gellert Blvd Ste G 650-757-1749 F/T 1 (PE, SP, TA) U

DAVISTwin Pines Dental #1675011109 Kennedy Pl Ste 4 530-753-9900 F/T 1 (SP)DUBLINLeida P Stine DDS Inc #1656017950 Dublin Blvd Ste 101 925-828-9993 F/T 1 (AR, TA, VI)Restore Smiles Dental #1653016990 Village Pkwy Ste 210 925-556-9074 F/T 1 (Hi, Ta) U

View Mobile Dental #1644017040 Dublin Blvd 925-225-9552 F/T 1 (TA)EL CERRITOArt Dental #16420110586 San Pablo Ave 510-559-8598 P/T 1 (CH, SP, VI) U

Rodney Kim, DDS #16330111100 San Pablo Ave Ste 107 510-233-9022 F/T 1 U

EL DORADO HILLSGreen Valley Dental Group #1577012205 Francisco Dr Ste 150 916-934-0207 P/T 2ELK GROVEAlpha Dental #1550018239 Laguna Blvd Ste 100 916-683-9080 P/T 1 (SP) U

Cozy Dental #1545012370 Maritime Dr 916-683-2272 F/T 4 (RU, SP)Elk Grove Dental Group #1517019640 Bruceville Rd Ste 101 916-686-9030 P/T 2 (SP) U

Elk Grove Landing Fmly Dtl #1501018351 Elk Grove Blvd Ste 300 916-691-6997 P/T 1 U

Smilecare-Elk Grove #1465019184 E Stockton Blvd 916-686-1101 F/T 2 P/T 7 (SP) U

VP Dental Care #1441019320 Elk Grove Blvd Ste 170 916-714-5422 P/T 1 U

EUREKAJames Foye, DMD #1436012805 G St 707-443-6392 F/T 1FAIR OAKSRiver City Dental Group #1433018908 Madison Ave 916-536-5151 P/T 1

FAIRFIELDAccess Dental #1426011600 Travis Blvd 707-429-4000 F/T 5 P/T 2 (SP) U

Dental Health Care #1424011555 Webster St Ste B 707-435-1906 P/T 1Dr Richard Ramos, DMD Inc #1421013075 Travis Blvd 707-435-9004 F/T 1 (TA) U

Julius Mosley II, DDS #1383012750 N Texas St Ste 340 707-421-2161 F/T 1 (TA) U

Smilecare-Fairfield #1375011955 W Texas St 707-428-5400 F/T 1 P/T 8 (SP) U

FOLSOMCosmetic Dental Studios #1374012700 E Bidwell St Ste 300 916-984-5552 F/T 1 (GE, PE, TR) U

Gateway Dental Group #1372012465 Iron Point Rd Ste 120 916-984-9600 P/T 2 (SP) U

Smile Time Dental #1365011568 Creekside Dr Ste 201 916-984-4224 F/T 5 (PE, RU, SP, TA) U

Smilecare-Folsom #136201825 E Bidwell St Ste 400 916-984-4591 F/T 4 P/T 6 (SP) U

FOSTER CITYJing-Jing Qian, DDS #1355011289 E Hillsdale Blvd Ste 3 650-572-8518 F/T 1 (CH)FREMONTAarisha Dental Office #13490143625 Mission Blvd Ste 105 510-656-7424 F/T 1 (HI, SP, TA)Advanced Smile Design #13470139560 Stevenson Pl Ste 117 510-797-8100 F/T 1 (HI, TA) U

American Dental Group #13300139624 Mission Blvd 510-744-1177 F/T 2 Brookevale Family Dentistry #13280139236 Argonaut Way 510-739-0701 F/T 2 P/T 2 (SP, VI) U

Dental Care Center #13240139470 Fremont Blvd 510-745-9222 F/T 1 (PE, SP, CH, HI)Duc Nguyen, DDS #12710139411 Fremont Blvd 510-438-9201 F/T 1Esquire Dental #12180137259 Fremont Blvd 510-790-0700 F/T 1Fremont Hills Dental Office #115101698 Mowry Ave 510-608-6097 F/T 1 (TA) U

Additional dental offices will be added as required. If any office is closed to further enrollment, Delta Dental reserves the right to assign you another dental office as close to your home as possible. All members of your family must be treated at the same facility.

LANGUAGE ASSISTANCE: Language capabilities are self-reported by the individual dental facilities and not independently verified by Delta Dental. If an enrollee requires language assistance to enable communication in a dental setting, Delta Dental will arrange for professional services through a certified interpretation vendor at no cost to the enrollee.

ATENCIÓN EN OTROS IDIOMAS: Las habilidades en idiomas son informadas por las instalaciones dentales individuales y no son verificadas independientemente por Delta Dental. Si un afiliado requiere ayuda en otro idioma para poder comunicarse durante la cita dental, Delta Dental coordinará los servicios profesionales mediante un proveedor certificado de interpretación sin costo para el afiliado.

Northern California Offices (Open)

DeltaCare USA Participating Dental OfficesPlease indicate the number of the office you have selected on the DeltaCare USA enrollment form.


ORTHODONTIC LIMITATIONSThe DeltaCare USA program provides coverage for orthodontic treatment plans provided through Contract Orthodontists. The start-up fees and the cost to the Enrollee for the treatment plan are listed in Schedule A, Description of Benefits and Copayments and subject to the following:

1. Orthodontic treatment must be provided by a Contract Orthodontist.

2. Benefits cover 24 months of active comprehensive orthodontic treatment. Included is the initial examination, diagnosis, consultation, initial banding, 24 months of active treatment, de-banding and the retention phase of treatment. The retention phase includes the initial construction, placement and adjustment to retainers and office visits for a maximum of two years.

3. Treatment plans extending beyond 24 months of active treatment, or 24 months of the retention phase of treatment will be subject to a monthly office visit fee to the Enrollee not to exceed $75.00 per month.

4. Should an Enrollee’s coverage be cancelled or terminated for any reason, and at the time of cancellation or termination be receiving any orthodontic treatment, the Enrollee and not Delta Dental will be responsible for payment of any balance due for treatment provided after cancellation or termination. In such a case the Enrollee’s payment shall be based on a maximum of $2,300.00 for covered dependent children to age 19 and $2,500.00 for covered adults and dependent adult children age 19 and older. The amount will be prorated over the number of months to completion of the treatment and, will be payable by the Enrollee on such terms and conditions as are arranged between the Enrollee and the Contract Orthodontist.

5. If treatment is not required or the Enrollee chooses not to start treatment after the diagnosis and consultation has been completed by the Contract Orthodontist, the Enrollee will be charged a consultation fee of $25.00 in addition to diagnostic record fees.

6. Three recementations or replacements of a bracket/band on the same tooth or a total of five rebracketings/rebandings on different teeth during the covered course of treatment are benefits. If any additional recementations or replacements of brackets/bands are performed, the Enrollee is responsible for the cost at the Contract Orthodontist’s “filed fees.”

7. Comprehensive orthodontic treatment (Phase II) consists of repositioning all or nearly all of the permanent teeth in an effort to make the Enrollee’s occlusion as ideal as possible. This treatment usually requires complete fixed appliances; however, when the Contract Orthodontist deems it suitable, a European or removable appliance therapy may be substituted at the same Copayment amounts as for fixed appliances.

8. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.

“Filed fees” means the Contract Orthodontist’s fees on file with Delta Dental. Questions regarding these fees should be directed to Delta Dental’s Customer Service department at 800-422-4234.

F/T – Number of full-time dentistsP/T – Number of part-time dentists

AF – AfrikaansAR – ArabicAM – ArmenianCA – CantoneseCH – ChineseCL – CreoleCS – CzechEI – East IndianFR – FrenchGE – German

GR – GreekHE – HebrewHI – HindiHR – CroatianHU – HungarianIN – IndonesianIT – ItalianJA – JapaneseKO – KoreanPE – Persian

PL – PolishRO – RomanianRU – RussianSP – Spanish/EspañolTA – TagalogTH – ThaiTR – TurkishVI – Vietnamese

Please call 800-422-4234 for updates to this list or check our online Dentist Directory at: www.deltadentalins.com/deltacareusa.

22 15

Hillview Dental Group #11490140739 Grimmer Blvd 510-651-1440 F/T 2 P/T 1 (SP)Rosalie S Geronimo, DMD Inc #0C84011956 Driscoll Rd 510-440-1406 F/T 1 (HI, TA, VI) U

Smilecare-Fremont #0C170139340 Fremont Blvd Dept 9532 510-739-3889 F/T 4 P/T 2 (SP) U

Star Dental #0C10015021 Mowry Ave 510-797-4900 F/T 1 (HI, SP) U

FRESNOAngels Family Dental #0C04013664 W Shaw Ave 559-277-5800 F/T 1 (AR, SP) U

Bullard Dental Group #085001323 E Bullard Ave Ste 104 559-439-9990 F/T 3First Family Dental #082801310 W Shaw Ave 559-229-8200 F/T 1 (SP)Frank Woo, DDS #0584013636 N 1St St Ste 126 559-243-1115 F/T 1 (SP)Fresno Dental Beechwood #0341923585 W Beechwood Ave Ste 102 559-432-0622 F/T 2 P/T 4 (SP) U

Fresno Dental Blackstone #0340416680 N Blackstone Ave 559-431-9111 F/T 1 P/T 5 (SP)Gallo Dental Group #0338115690 N Fresno St Ste 101 559-436-3470 F/T 1 P/T 1 (SP) U

Lauro So, DMD #0337351436 E Olive Ave 559-485-0340 F/T 1 (SP, TA)Northside Dental Practice #0336868835 N Cedar Ave 559-446-1350 F/T 2 (SP, VI)Ronald Nowell, DDS #0336855412 N Palm Ave Ste 109 559-432-0400 F/T 1 U

Sam Akande, DDS #033681 1902 E Ashlan Ave 559-228-3000 P/T 1 (SP)Sami Youssef, Dds #0336314755 E Gettysbrg Ave Ste 101 559-292-4444 P/T 2 (SP) U

Smilecare - Sunnyside #0334345657 E Kings Cyn Rd Ste 107 559-454-7900 F/T 3 P/T 6 (Sp)Smilecare-Fresno #0333662745 W Shaw Ave Ste 103 559-227-2900 F/T 3 P/T 9 (SP) U

Smilecare-Manchester Mall #0330631901 E Shields Ave Ste 226 559-226-2626 F/T 3 P/T 7 (SP) U

St George Quality Dental #0330181515 W Shaw Ave Ste 101 559-227-1700 F/T 1 P/T 1 (AM, AR, RU, SP)Tower Dental Care #0328791215 N Del Mar Ave 559-233-5625 F/T 1 (SP)White & Bright Family Dental #0328526073 N Fresno St 559-432-6384 F/T 1 (PE, SP)GALTGalt Plaza Dental #0327151067 C St Ste 125 209-744-0463 F/T 1 P/T 1 (HI, RU, SP)Sirak Workneh, DDS #032650430 Pine St 209-744-9917 P/T 1 (SP, RU, CH)GREENFIELDRafid Khamis, DDS #032638329 El Camino Real 831-674-0235 F/T 1 (SP) U

HAYWARDDental Solutions/Dr Shtulman #03233019682 Hesperian Blvd Ste 101 510-782-9942 P/T 1 (RU, SP)Fairway Park Dental Office #03227131111 Mission Blvd 510-477-6887 F/T 1 (SP, TA)Gan Dental Care #03210530512 Mission Blvd Ste 100 510-471-1500 F/T 4 P/T 1 (SP, VI) U

Kelvin Cai, DDS #0320541689 Industrial Pkwy W 510-264-9074 P/T 1 (CA, SP)

Smilecare-Hayward #03203422421 Hesperian Blvd 510-782-4161 F/T 4 P/T 4 U

HERCULESDental Center of Hercules #031953844 Willow Ave Ste A6 510-245-3004 F/T 1 (SP, TA) U

King CityJose Cardenas, DDS #031828105B Broadway St 831-386-0148 P/T 1LINCOLNCitadel Dental #031827941 Sterling Pkwy Ste 100 916-408-8585 P/T 1 (GE, PE, RU, TR)Lincoln Hills Family Dental #0315502295 Fieldstone Dr Ste 100 916-543-0222 P/T 1 U

Parkway Dental Group #031208781 Sterling Pkwy 916-543-7880 F/T 2 P/T 1 (SP) U

LIVERMORECountry Club Dental Care 031197 1046 Murrieta Blvd 925-456-7600 P/T 1 (HI, RU, SP)Livermore Dental #031123867 E Stanley Blvd 925-243-6491 F/T 1 P/T 1 (Ei, Sp)LODILodi Dental Group #031122531 W Kettleman Ln 209-366-1850 P/T 1 (SP)LOS ALTOSLos Altos Dental Spa #031062919 Fremont Ave Ste 200 650-917-9603 F/T 1 (FR, SP) U

Samson Fu-Keung Lee, DDS #031027763 Altos Oaks Dr Ste 3 650-948-6075 F/T 1 (SP)LOS GATOSLos Gatos Dental Care #031026555 Knowles Dr Ste 112 408-370-7733 F/T 1 (AR, FR, SP) U

Ronald Matsuura, DDS #030836431 Monterey Ave Ste 6 408-354-1717 F/T 1 (SP, VI)MADERANorthwest Dental Care #030822 2295 W Cleveland Ave Ste D 559-674-0927 F/T 1 MANTECAStadium Dental Group #030705 2288 Daniels St 209-456-5610 F/T 1 P/T 1 (SP) U

MARTINEZMartinez Dental #0305831160 Arnold Dr Ste G 925-372-7100 F/T 3 P/T 3 (SP, TA) U

Parkway Smiles Dental #0305231029 Arnold Dr Ste 9 925-229-8890 F/T 1 U

MENLO PARKJoseph K Sarkosh, DDS #030245888 Oak Grove Ave Ste 6 650-327-8081 P/T 1 (SP)MERCEDAccess Dental #030033 12 W 20th St 209-388-1000 F/T 3 (AM, SP) U

MILLBRAECecilia Ju, DDS #029990140 El Camino 650-259-9896 F/T 1 (CH)Dental Ease #0299891070 Broadway 650-697-3273 P/T 1 (AR, SP, TA)Pedro Caturay, DDS #0298821301 Broadway Ste 7 650-589-3667 P/T 1MILPITASKim Luu, DDS #0298371105 S Park Victoria Dr 408-263-3090 F/T 1 (SP, VI)Madhvi Desai, DDS #02983540 N Park Victoria Dr Ste D 408-263-0371 F/T 1 (SP, HI)Nisha Dharmani, DDS #029718430 E Calaveras Blvd 408-263-9714 F/T 1 (HI, SP, VI) U

Radiant Dental Care #02971510 S Hillview Dr 408-719-1643 F/T 1 (VI, SP) U

MODESTOAlan Vincent, DDS #029379105 Melrose St 209-522-0411 F/T 1Coffee Family Dental #0292691130 Coffee Rd Ste 1A 209-523-5991 P/T 2 (SP, HI)Modesto Dental #0291212225 Plaza Pkwy Ste P1 209-576-8181 F/T 2 P/T 2Pelandale Dental Care #0289783900 Pelandale Ave Ste 135 209-545-9282 P/T 1 (RU, SP, HI) U

Smilecare-Modesto #0288402900 Standiford Ave Ste 2 209-577-5008 F/T 3 P/T 2 (SP)MORGAN HILLCondit Dental #02871417020 Condit Rd Ste 180 408-778-4548 F/T 1 (VI) U

Morgan Hill Dental Care #028713154 Cochrane Plz 408-778-4838 F/T 1 P/T 1 (SP, VI) U

South Valley Dental #02841315870 Monterey St 408-778-6684 F/T 1 (SP, VI) U

MOUNTAIN VIEWAfshin Abdollahi, DDS #028290285 South Dr 650-988-0787 P/T 2 (SP)California Family Dental #0282812425 California St Ste D 650-967-1389 F/T 1 (HI, SP)Camino Family Dentistry #028184451 W El Camino Real Ste B 650-938-9002 F/T 1 (SP, TA) U

Christine Thai, DMD #0280942500 Hospital Dr Bldg 1 # 5 650-961-5070 P/T 1Donian Shen, DDS #028071105 South Dr Ste 140 650-938-1868 F/T 1 (CA, JA, SP, TA)Olive Tree Dental #0280662290 W El Camino Real Ste 3 650-938-8870 F/T 1 (TA) U

San Antonio Dental #028063530 Showers Dr Ste 3 650-917-8348 F/T 2 (CH, SP) U

NAPATrancas Dental Group #028062935 Trancas St Ste 4E 707-257-6277 F/T 4 P/T 1 (SP)NEWARKAll Smile Dental Center #02805537070 Newark Blvd Ste E 510-790-8268 P/T 1 (CA, CH, SP) U

Scott Nguyen, DDS #0279926180 Jarvis Ave Ste J 510-795-9669 F/T 1NORTH HIGHLANDSSmilecare Dental Group #0278243901 Madison Ave Ste 5 10 916-339-9000 F/T 5 P/T 6 (SP) U

OAKLANDBay Area Dental #027639 475 8th St 510-763-7400 F/T 1 U

City Center Dental Spa #027422300 F H Ogawa Plz Ste 100 510-763-6300 F/T 1 (SP) U

East Bay Family Dentistry #0271393040 E 9th St Ste D 510-534-0706 P/T 3 (SP) U

Elegant Smiles #0271273301 E 12th St Ste 165 510-533-5500 F/T 1 P/T 3 (SP) U

Family Dentists #0269931510 Franklin St 510-893-1923 F/T 1 (SP)Franklin Dental Care #0269331624 Franklin St Ste 1220 510-893-4041 F/T 1 P/T 1 (KO, SP) U

Oakland Dental #0268608105 Edgewater Dr 510-568-6272 F/T 2 P/T 3 (SP)Oakland Dental Care #0265771700 Broadway 510-444-6300 F/T 1 (SP)Timothy Han, DDS #026559320 13th St Ste 301 510-839-2045 P/T 1 (KO)

Timothy Han, DDS #0265252710 Telegraph Ave Ste 250 510-839-4106 P/T 1 (KO, TA)PALO ALTOPalo Alto Dental Care #0265053737 El Camino Real 650-858-2028 F/T 2 P/T 1 (CA, CH, HI, RU, SP) U

PARLIERDiljeet Heer, DDS #026471545 E Manning Ave Ste 108 559-646-3844 F/T 1 (SP, HI) U

PETALUMAMichael Haglund, DDS #026261765 Baywood Dr Ste 101 707-762-5561 F/T 1 U

Petaluma Dental Care #0261871436 Professional Dr Ste 302 707-763-2828 P/T 1 (SP, FR, PE)Petaluma Family Dental Care #02618135 Maria Dr Ste 854 707-763-3203 F/T 1 P/T 1Premier Dental Care #026176229 N Mcdowell Blvd 707-766-7373 F/T 1 (FR, GE, SP) U

Surya Manga Achyuta, DDS #0260821372 N Mcdowell Blvd Ste B1 707-778-9993 F/T 1 P/T 1 (HI, PE, TA) U

PINOLEPinole Dental #0260811477 Fitzgerald Dr Ste 106 510-669-0350 F/T 4 P/T 1PITTSBURGSky Dental #0260382230 Gladstone Dr Ste 100 925-432-2444 F/T 2 P/T 1 (PE, SP, TA) U

PLACERVILLEBrookside Dental #0260364330 Golden Center Dr 530-622-1987 F/T 1 U

Placerville Dental & Ortho #026025699 Main St Ste B 530-295-8000 F/T 1 U

PLEASANT HILLDiablo Valley Dental Care #02587630 Golf Club Rd Ste C 925-685-8633 F/T 1 P/T 2 (CH, SP) U

PLEASANTONAlisal Dental Care #0258745933 Coronado Ln Ste 2F 925-846-6308 F/T 2Bay Family Dental Care #025873173 Spring St Ste 110 925-600-9006 P/T 1 (PE)Bernal Dental Group #0257104466 Black Ave Ste K 925-485-1172 F/T 1 P/T 1 (CH, HI)Tri-Valley Dental #0256815820 Stnrge Mall Rd Ste 118 925-225-1555 F/T 1 (KO, SP, TA)RANCHO CORDOVARancho Cordova Dental Group #02567910390 Coloma Rd Ste A 916-368-0440 P/T 1 (KO, CH, RU) U

River City Dental Group #02567810910 Olson Dr Ste 100 916-638-3780 F/T 1 P/T 1 U

St Mary Family Dental Office #02556811050 Coloma Rd Ste 17 916-635-9800 F/T 1 (SP) U

REDDINGAccess Dental #0255672147 Court St 530-246-4100 U

Access Dental #0254701667 Hilltop Dr 530-223-5500 F/T 2 U

REDWOOD CITYBay Area Dental Office #02546929 Birch St Ste 3 650-587-3788 F/T 1Birch Dental Group #025284155 Birch St Ste 5 650-366-0552 P/T 1Eugene Espiritu #025253705 Veterans Blvd Ste Suite1 650-298-8818 P/T 1 (TA, CA, CH, SP)Laluces Dental #0252462480 El Camino Real 650-216-8488 F/T 1United Dental #025083647 Veterans Blvd 650-367-4300 P/T 1 U

RICHMONDWinning Smile Dental Group #02508012732 San Pablo Ave 510-233-3100 F/T 1ROCKLINHealthy Smiles Family Dntstry #0250352160 Sunset Blvd Ste 503 916-771-0757 F/T 1 (CA) U

Highland Dental Grp #0248943291 Stanford Ranch Rd # 102 916-435-1665 P/T 2Martin Kerzie, DMD #0248554970 Rocklin Rd Ste 100 916-626-5525 F/T 2Smile Time Dental #0248506000 Fairway Dr Ste 8 916-632-0404 F/T 1 P/T 2ROHNERT PARKLora H Costa, DDS #0246911331 Medical Center Dr Ste H 707-585-8599 P/T 1 (TA, SP, VI) U

Rohnert Park Dental #0246525755 Redwood Dr 707-584-1000 F/T 2 P/T 2 U

ROSEVILLEAesthetic Dentistry #0244458445 Sierra College Blvd # B 916-773-0505 F/T 1 (AM, RU) U

American Family Dentistry #0244441160 Cirby Way #100 916-789-8530 F/T 2 (PE, RU, SP) U

Healthy Image Dental Group #024315576 N Sunrise Ave Ste 140 916-786-6431 F/T 2 P/T 1 (VI) U

Healthy Impressions Dental #024308730 Sunrise Ave Ste 120 916-797-0868 P/T 1Hetal Rana, DDS #0242761422 Blue Oaks Blvd Ste 130 916-774-4499 F/T 1 (HI) U

Interdental Care #024221106 N Sunrise Ave Ste B10 916-787-0631 F/T 1 (SP, RU, TA, CH, VI) U

Pavilions Dental Group #0240221259 Plsnt Grv Blvd Ste 100 916-782-2010 F/T 1 P/T 1 (SP)Pleasant Grove Dental Group #02402110357 Fairway Dr Ste 100 916-782-4500 P/T 2 U

River City Dental Group #0240201079 Sunrise Ave Ste C 916-784-3101 P/T 1 (SP) U

Rocky Ridge Family Dental #0240191700 Rocky Ridge Dr Ste 100 916-782-6001 P/T 1 U

Roseville Dental! #023862960 Sunrise Ave Ste 115 916-772-9300 P/T 4Said Shaari, DDS #023836406 1/2 Sunrise Ave Ste 270 916-789-4568 P/T 1 (FR) U

Shailesh Jawale, DDS #023833928 Plsnt Grv Blvd Ste 100 916-772-1367 F/T 1Siamak Okhovat, DDS #0236932110 Professional Dr Ste 115 916-783-5600 F/T 1 (GE, PE) U

Star Dental #0236892030 Douglas Blvd Ste 37 916-773-6222 F/T 2 (PE, SP) U

SACRAMENTOArden Oaks Dental Care #0236881741 Professional Dr 916-485-5539 F/T 1 U

Brent Varshawsky, DMD #0236871901 Watt Ave Ste 2 916-483-5677 F/T 1Brian C Steele, DDS #0236651115 12th St # 2A 916-443-4430 P/T 1 (SP) U

Charles Tran, DDS #0236526175 Stockton Blvd Ste 260 916-427-6263 F/T 1 (CH, SP, VI) U

De La Osa DDS Inc #0236157315 Stockton Blvd Ste 3 916-422-8332 F/T 1 (SP)Elder Creek Dental #0235804730 47th Ave 916-391-0682 F/T 1 (KO, VI)Greenhaven Dental Group #023542925 Secret River Dr Ste B 916-421-3993 F/T 1 P/T 1


15. Appliances or restorations necessary to increase vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings, equilibration or treatment of disturbances of the temporomandibular joint (TMJ).

16. An initial treatment plan which involves the removal and reestablishment of the occlusal contacts of 10 or more teeth with crowns, onlays, fixed partial dentures (bridges), or any combination of these is considered to be full mouth reconstruction under the DeltaCare USA program. Crowns, onlays and fixed partial dentures associated with such a treatment plan are not covered Benefits. This exclusion does not eliminate the benefit for other covered services.

17. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures.

18. Extraction of teeth, when teeth are asymptomatic/non-pathologic (no signs or symptoms of pathology or infection), including but not limited to the removal of third molars and orthodontic extractions.

19. Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent.

EXCLUSIONS OF BENEFITS1. Any procedure that is not specifically listed under Schedule A,

Description of Benefits and Copayments.

2. Dental conditions arising out of and due to Enrollee’s employment for which Workers’ Compensation is paid. Services which are provided to the Enrollee by state government or agency thereof, or are provided without cost to the Enrollee by any municipality, county or other subdivision, except as provided in Section 1373(a) of the California Health and Safety Code.

3. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility.

4. Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges).

5. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage.

6. Dental expenses incurred in connection with any dental procedure started before the Enrollee’s eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, orthodontics.

7. Congenital malformations (e.g. congenitally missing teeth, supernumerary teeth, enamel and dentinal dysplasias, etc.), except for the treatment of newborn children with congenital defects or birth abnormalities.

8. Dispensing of drugs not normally utilized in the delivery of dental services.

9. Any procedure that in the professional opinion of the Contract Dentist:

a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/ or surrounding structures, or

b. is inconsistent with generally accepted standards for dentistry.

10. Dental services received from any dental facility other than the assigned Contract Dentist including the services of a dental specialist, unless expressly authorized in writing by Delta Dental or as cited under Emergency Services. To obtain written authorization, the Enrollee should call Delta Dental’s Customer Service department at 800-422-4234.

11. Consultations for non-covered benefits.

12. Implant placement or removal, appliances placed on or services associated with implants, including but not limited to prophylaxis and periodontal treatment.

13. Fixed partial dentures (bridges) for children under 16 years of age.

14. Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformation of teeth.

2314

Irvin Ramsey, Dds #023474 905 Secret River Dr Ste C 916-393-2587 U

Lp Dental Care of Loan Pham #0234596830 Stockton Blvd Ste 185 916-422-5628 F/T 1 (VI) U

Madison Dtl Care #0232885149 Madison Ave 916-338-3880 F/T 1Market West Dental Group #0232683290 Arena Blvd Ste 610 916-574-9400 F/T 1 P/T 1 (SP) U

Miracle Smile-Dezham Dntl Grp #0232272131 Capitol Ave Ste 100 916-441-3311 F/T 2 (PE, RU, SP) U

More Smiles Dental #0231902020 Hurley Way Ste 135 916-641-7700 F/T 1 U

Natomas Dental Care #0231872321 Northgate Blvd 916-564-8088 P/T 1 U

New Dental Images #0231386624 Valley Hi Dr 916-688-1990 F/T 1 (SP, TA, VI)Odean Loney, DMD #023129905 Secret River Dr Ste A 916-428-5318 F/T 1 U

Pacific Plaza Family Dental #0231286930 65th St Ste 107B 916-422-5697 F/T 2 (CH, SP, VI) U

Park Place Dental Group #0230074690 Natomas Blvd Ste 100 916-515-4500 P/T 1 U

Paul Shieh, DDS #0228675659 Stockton Blvd 916-456-8625 F/T 1Pioneer Family Dental #0228587850 Stockton Blvd Ste 160 916-689-3310 F/T 3 (CH, PE, SP, TA, VI) U

Pro Dental Group #022838 1111 24th St Ste 201 916-442-5228 P/T 1 U

Promenade Dental Group #0227523635 N Freeway Blvd Ste 110 916-285-6691 P/T 2 (Sp) U

Sacramento Dental #022751591 Watt Ave Ste 100 916-481-5057 P/T 3 (SP)Sacramento Dental Arts #0227503428 Watt Ave Ste B 916-489-9990 P/T 2 (SP)Said Shaari, DDS #02264077 Cadillac Dr Ste 270 916-649-8200 P/T 1 (CH, PE, RU, SP)Sandhu Dental Group #0224843811 Florin Rd Ste 8 916-392-7020 P/T 1 (SP, HI) U

Scripps Dental Group #02246279 Scripps Dr Ste 204 916-565-2570 P/T 1Serena Pugeda, DMD #0217932518 L St Ste A 916-446-7768 F/T 3 (TA)Signature Dental #0216964321 Truxel Rd Ste F5 916-515-1588 F/T 1 (VI) U

Smile Makers #0216921906 Del Paso Rd 916-263-9888 P/T 3 (CH, CA) U

Stonebrook Dental #021635911 Howe Ave 916-920-1170 F/T 1 (HI, SP) U

Strawberry Creek Dental Grp #0214898211 Bruceville Rd Ste 155 916-525-7635 F/T 1 P/T 1 U

Unique Dental #0214227300 Franklin Blvd Ste 104 916-428-4325 F/T 1 P/T 1 (SP, TH, CH, GE, RU)Vicente Alindogan, DDS #0214218876 Vintage Park Dr Ste 105 916-681-2751 F/T 1 (TA) U

VP Dental Care #0213913337 El Camino Ave 916-486-8240 F/T 1 (SP, VI) U

West Florin Dental #021389930 Florin Rd Ste 100 916-706-1915 F/T 1 (SP, VI)Yolanda Gonzales, DMD #0211492378 Fruitridge Rd 916-421-1010 F/T 1 U

SALIDASalida Dental Group #0210485708 Pirrone Rd 209-543-3888 F/T 1SALINASDiamond Dental of Salinas #0210471209 N Davis Rd 831-424-4111 F/T 1 U

Peter Yang, DDS #02100411 Maple St Ste E 831-753-6598 F/T 1 (SP)Steinbeck Cntry Dtl Practice #020997535 E Romie Ln Ste 10 831-758-5836 F/T 2 (SP)SAN BRUNOEugene Espiritu #0209951230 El Camino Real Ste K 650-875-6808 P/T 1 (SP)San Bruno Dental Care #020994211 El Camino Real 650-589-4784 F/T 2 (GE, SP, TA) U

SAN FRANCISCOBernardo Gonzalez, DDS #0209432720 24th St 415-282-4566 F/T 1 (SP)Center of Cosmetic Dentistry #0209421550 Lombard St 415-921-5555 P/T 1Gentle Dental #0205172494 Mission St 415-821-1200 F/T 6 P/T 4 (RU, SP)Gentle Dental San Francisco #0203542364 Geary Blvd 415-921-6722 F/T 1 P/T 2 (CA, CH)Grand Mission Dental Group #0203224749 Mission St 415-469-7444 F/T 2 (TA, SP)Hipolito Baronia, DDS #020283 2480 Mission St Ste 214 415-821-7847 F/T 1 (SP, TA)J T Dental #0199852415 Noriega St 415-682-2415 F/T 1 (CA)Kayvan Kafayi, DDS #019966450 Sutter St Rm 1433 415-398-2360 F/T 1 (CH, FR, GE, IT, PE, SP)Mat Kiisk, DDS #0199603100 19ThAve 415-584-2537 F/T 2 (SP, TA, HI, JA)Melissa Chavez, DDS #0196902460 Mission St Ste 201 415-821-0101 F/T 1Michael Cole, DDS #0196332595 Mission St Ste 308 415-647-9191 F/T 1 (SP)Mikhail Berdichevsky, DDS #019514 4444 Geary Blvd Ste 303 415-386-5590 F/T 1 P/T 1 (RU) U

Noriega Dental #0194203749 Noriega St 415-661-8851 F/T 1 (CH)Ocean View Dental #019254760 La Playa St 415-221-5592 F/T 2 P/T 1 (CH, RU, SP, TA)Richmond Dental Care #0192534312 Geary Blvd 415-752-5605 F/T 2 (CH, RU, SP) U

Roberto Calabio DMD Inc #0192423184 22Nd St 415-642-2050 F/T 1 (TA)Ronald Young, DDS #0192401637 Lombard St 415-928-3777 F/T 1 (CH, SP)San Bruno Ave Dental Clinic #0190492817 San Bruno Ave 415-656-2868 F/T 1 (CH) U

South Van Ness Dental Group #019048240 Shotwell St Ste 230 415-431-9797 F/T 1 P/T 1 (CH, VI)Van Ness Dental Group #0190472243 Van Ness Ave Ste 101 415-441-2098 F/T 4 (CA, CH, SP, VI)SAN JOSEAdrienne Van, DDS #0189282114 Senter Rd Ste 14 408-298-9951 P/T 1 U

Afshin Abdollahi, DDS #0185751300 Meridian Ave 408-979-0808 F/T 1 P/T 1 (PE, SP)

All Star Dental #018513259 Meridian Ave Ste 12 408-275-0768 F/T 1 (PE, SP, TA)Berryessa Fmly Dentistry #0185112664 Berryessa Rd Ste 201 408-272-2330 P/T 1 (TA, SP)Big Smiles Dental Care #0182641547 Saratoga Ave 408-725-3740 F/T 1Comfort Dental Group #0181692881 Hemlock Ave # A 408-249-8888 F/T 1 (PE, VI, TA)David Meng, DDS Inc #0180462505 Samaritan Dr Ste 308 408-356-3588 P/T 1Dental Concepts Eastridge #017745 2200 Eastridge Loop Ste 1060 408-238-6684 F/T 1 (CH, SP, KO, HI, TA, VI) U

Evergreen Dental Grp #017744 3162 Newberry Dr 408-274-9600 F/T 1 (SP)Fariba Alikhani, DMD #017703 3575 Stevens Creek Blvd # L 408-247-3400 F/T 1 (SP, PE, TA)Gurdip Narula, DDS #0176662850 Quimby Rd Ste 145 408-274-5000 F/T 4 (HI, SP, TA) U

Healthy Smiles Family Dent #0176042664 Berryessa Rd Ste 107 408-258-1323 F/T 1 (HI, SP) U

Huong Nguyen, DDS Inc #017551266 N Jackson Ave Ste 3 408-258-2207 F/T 1 (SP, VI)Image Dental #0175482493 Alvin Ave 408-223-0988 P/T 1 (SP, VI)Irma Francisco DDS Inc #0174814750 Almaden Expy Ste 152 408-264-5880 F/T 1 (CA, JA, SP, TA, VI)Jackson Family Dental #0174692324 Montpelier Dr Ste 3 408-937-5950 F/T 2 (SP)Jasna Galeb, DDS #0174291547 Saratoga Ave 408-725-8331 P/T 1 (HR, RU)Joel Santos, DDS #017363200 N Jackson Ave Ste D 408-254-7491 F/T 1 (TA)John Tanaka, DDS #0172462034 Forest Ave Ste 1A 408-279-8080 F/T 1 (JA, KO, SP, HI)John Vu, Dds #0172211399 S Wnchester Blvd # 120 408-370-7767 P/T 1 (VI, SP) U

Kini Dental Care #017161 100 Oconnor Dr Ste 23 408-998-8383 F/T 1 (HI, SP) U

Kini Gentle Dental Care #017147827 Blossom Hill Rd Ste W5 408-226-1060 P/T 1La Amistad Dental Office #01684922N White Rd 408-254-4402 F/T 1 (SP)Lexann Dentals Corp #0167701569 Lexann Ave Ste 108 408-270-4211 F/T 1 (SP, VI) U

Muu Vu, DDS #0165692340 Mckee Rd Ste 3 408-923-6400 P/T 1 (VI, SP) U

Muu Vu, DDS #0162381569 Lexann Ave Ste 102 408-223-0104 P/T 1 (SP, VI) U

Ngoc Ly Pham, DDS #016236648 E Santa Clara St 408-287-0913 F/T 1 (SP, VI)Oakridge Dental #0162045450 Thornwood Dr Ste B 408-360-0270 F/T 1 (SP, PE, RU, HI) U

One Stop Dental #0161751155 S King Rd 408-928-5678 F/T 2 (CH, SP, VI)Portia Dela Vega Oblea DMD #0161732356 Senter Rd 408-993-9939 F/T 1 (SP, TA)Pro-Tech Dental Care #0158652664 Berryessa Rd Ste 210 408-258-8903 F/T 1 (VI, TA) U

Quach DDS A Professional Corp #01568088 Tully Rd Ste 103 408-279-9888 P/T 1 U

San Jose Dental #0156772930 Aborn Square Rd 408-238-1853 F/T 4 P/T 2 U

Setty Dental Corporation #0155721705 Branham Ln Ste B30 408-264-7630 F/T 1 P/T 1 (HI, SP, TA, VI) U

Silicon Dental #0154322060 Aborn Rd Ste 210 408-238-5500 P/T 1 (HI, SP)Smilecare-San Jose II #0154315130 Stevens Creek Blvd 408-557-9830 F/T 3 P/T 4 (SP)Story Dental Health Cntr Inc #0154302454 Story Rd 408-272-0888 F/T 1 P/T 1 (SP)Tianna Dao, DDS #0153992344 Mckee Rd Ste 10 408-926-9300 F/T 1 (SP, VI)Tuyen Nguyen, DDS #015202634 E Santa Clara St 408-286-6156 F/T 1 (VI, FR, SP)Uni Dental #014891175 S Capitol Ave Ste E 408-923-3073 F/T 1 (SP, VI)Unident #0148772390 Senter Rd 408-298-6420 P/T 1 (PE, SP, VI)Unismile Dental #0148766134 Camino Verde Dr Ste G 408-226-1600 F/T 1 (HI, SP, TA) U

Valley Dental Plaza #0146301664 Story Rd 408-937-9849 F/T 1 (SP, TA) U

Valley Family Dental Care #0146292060 Aborn Rd Ste 150 408-239-0816 F/T 1 (VI)William Thai, DDS #014628 630 E Santa Clara St 408-995-5424 F/T 1 (VI)Willow Dental Care #0143391675 Willow St 408-264-8700 F/T 1 (SP, TA) U

SAN LEANDRO Andy Q V Le Dds #0141551600 150ThAve 510-276-5533 P/T 1 (CA, VI) U

Smilecare-San Leandro #01414215301 Washington Ave 510-351-6820 F/T 3 P/T 5 U

SAN MATEOGeorge Wolff, DDS #014096255 N San Mateo Dr 650-347-7100 F/T 1Huyang Wu, DDS #0140951919 Ofarrell St Ste 1 650-571-6666 F/T 1Peninsula Dental #013976401 A N San Mateo Dr 650-344-7626 P/T 2SAN PABLOContra Costa Dental #01386514330 San Pablo Ave Ste B 510-234-1414 P/T 1 (Hi, Sp, Ta, Vi) U

Reach Dental Care #0137714200A Klose Way 510-223-8228 F/T 2 P/T 1 (CH, RU, SP, TA)SAN RAFAELPacific Dental Group #0135531523 5ThAve 415-453-6277 F/T 1 P/T 1 (SP, CH)San Rafael Dentistry #013447905 Lincoln Ave 415-453-1241 F/T 1 (SP)SAN RAMONCountry Fair Dental #01333412111 Alcosta Blvd 925-829-3111 F/T 2 P/T 2 (CH, HI, KO, SP) U

Perfect Smiles Fmly Dentistry #0132959260 Alcosta Blvd Ste B10 925-833-8702 P/T 1 (TA) U

San Ramon Family Dental #0132873160 Crow Canyon Rd Ste 100 925-866-8422 F/T 1 (HI, VI)Smilecare Dental Group #0132119130 Alcosta Blvd Ste A 925-803-9700 F/T 3 P/T 4 (SP)SANTA CLARAApex Family Dental #0131592797 El Camino Real 408-247-4871 F/T 1 (CH, SP, VI) U

Bruce Dental Corpation #0131391500 Los Padres Blvd Ste 101 408-244-3867 F/T 1 (SP, TA)Northern Dental #013133122 Saratoga Ave 408-556-1333 F/T 3 P/T 1 (SP, PE, TA)Paulette Sanford, DDS #013132310 N Winchester Blvd 408-241-6501 F/T 1Silicon Valley Dental #0131242975 Bowers Ave Ste 100 408-987-0530 F/T 1 (CH, FR, HI, JA, SP, VI)Star Dental #013123980 El Camino Real Ste 250 408-247-3740 F/T 2 (RU, TA, SP)Syed Dental Care, Inc #0127541150 Scott Blvd Ste A2 408-554-5855 F/T 1 (SP, AR)SANTA CRUZGayane Mooradian, DDS #012687550 Water St Ste J1 831-425-5515 F/T 1 (AM, FR, PE, SP)SANTA ROSABright Care Dental #0126531420 Guerneville Rd Ste 2 707-578-3776 F/T 1 U

Charles Aikawa, DDS #012522397 Aviation Blvd Ste L 707-579-1201 F/T 2 (SP) U

Essential Dental Care #01238755 Mission Cir Ste 103 707-568-0480 F/T 2 (FR, PE, SP)Plaza Dental #0121091017 Santa Rosa Plz 707-575-7240 F/T 1 P/T 1 (SP)Smilecare Dental Group #012105140 Stony Point Rd Ste A 707-578-3118 F/T 1 P/T 1 (SP)SARATOGAProspect Dental Care #01207519888 Prospect Rd Ste B 408-252-6000 F/T 2 (PE, FR, SP)Sahana Prasad, DDS #01203312860 Saratoga Sunnyvale Rd 408-867-1800 F/T 1 (HI, SP, TA) U

SOUTH SAN FRANCISCOGrand Mission Dental Group #011889 125 Northwood Dr Ste A 650-225-0202 F/T 2 (SP, TA)Jeanette Estipona, DDS #0118881133 El Camino Real Ste 4 650-296-6952 F/T 1 (TA)Northwood Dental Care #011568 125 Northwood Dr Ste A 650-827-9746 F/T 1 (TA)Trinity Dental Care #0115051124 Mission Rd 650-872-3030 F/T 1 (TA)Winston Manor Dental Office #011404101 Hickey Blvd Ste C 650-991-4848 F/T 1 (TA)STOCKTONAccess Dental #011118902 E Hammer Ln 209-957-9500 F/T 3 P/T 2 (CH, SP) U

Caring Dental Center #0107628014 Lower Sac Rd #B 209-478-9999 P/T 2 (HI, RU, SP) U

Kevin Thang Pham, DDS PC #0107063322 E Hammer Ln Ste H 209-475-0869 F/T 1 (SP, VI) U

Maria Theresa Oronce, DMD #0104991610 N El Dorado St Ste 4 209-462-8361 F/T 2Nu Smile Dental #010498707 E March Ln Ste 1 209-955-1800 F/T 1 (HI, SP) U

Park West Dental Group #010387 10928 Trinity Pkwy 209-474-8000 P/T 2 (SP) U

Simon Trenchuck, DDS #0103861341 W Robinhood Dr Ste C3 209-957-0765 F/T 1Smilecare Dental Group #0103835756 Pacific Ave Ste 75 209-472-1765 F/T 3 P/T 5 (SP) U

So. California Dtl Practice #01009540 S California St 209-941-0814 P/T 1 (SP, HI, CH) U


b. Either of the following:

b. — The existing non-functional restoration/bridge/denture was placed five or more years prior to its replacement, or

b. — If an existing partial denture is less than five years old, but must be replaced by a new partial denture due to the loss of a natural tooth, which cannot be replaced by adding another tooth to the existing partial denture.

13. A direct or indirect pulp cap is a benefit only on a vital permanent tooth with an open apex or a vital primary tooth.

14. With the exception of pulp caps and pulpotomies, endodontic procedures (e.g. root canal therapy, apicoectomy, retrofill, etc.) are only a benefit on a permanent tooth.

15. A therapeutic pulpotomy on a permanent tooth is limited to palliative treatment when the Contract Dentist is not performing root canal therapy.

16. Periodontal scaling and root planing are limited to five quadrants during any 12 month period.

17. Full mouth debridement (gross scale) is limited to one treatment in any 12 month period.

18. The benefit for the replacement of a missing posterior tooth (or teeth) is a removable partial denture. Coverage for the placement of a fixed partial denture (bridge) is optional except in the following cases:

— The sole tooth to be replaced in the arch is a permanent anterior tooth, provided it is not in connection with a partial denture on the same arch; or

— The new bridge would replace an existing, non-functional bridge utilizing the same abutment teeth, with no additional abutments or pontics with the exception of posterior cantilever bridges (see Limitation #12); or

— The abutment teeth are not being crowned solely for the purpose of supporting a pontic (each abutment tooth to be crowned must meet Limitation #8).

19. Relines, tissue conditioning and rebases are limited to one per denture during any 12 consecutive months.

20. Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited to:

— The replacement of extracted anterior teeth for adults during a healing period when the teeth cannot be added to an existing partial denture or

— The replacement of permanent tooth/teeth for children under 16 years of age.

21. Retained primary teeth shall be covered as primary teeth.

22. Excision of the frenum is a benefit only when it results in limited mobility of the tongue, it causes a large diastema between teeth or it interferes with a prosthetic appliance.

23. Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract Dentist to treat the child and upon prior authorization by Delta Dental, less applicable Copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis.

24. In cases of accidental injury, benefits available are described in Schedule B, Accident Injury Benefit. Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing) function, exclusive attrition and normal wear, will be covered as described in Schedules A, Description of Benefits and Copayments; and B, Limitations and Exclusions of Benefits.

25. Soft tissue management programs include, but are not limited to, periodontal pocket charting, root planing, scaling, curettage, oral hygiene instruction, periodontal maintenance and/or prophylaxis. If an Enrollee declines non-covered services within a soft tissue management program, it does not eliminate or alter the benefit for covered services.

26. A new removable partial, complete or immediate denture includes after delivery adjustments and tissue conditioning at no additional cost for the first six months after placement if the Enrollee continues to be eligible and the service is provided at the Contract Dentist’s facility where the denture was originally delivered.

27. An Optional procedure is defined as any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the limitations and exclusions of the program. The applicable charge to the Enrollee is the difference between the Contract Dentist’s “filed fees” for the Optional procedure and the “filed fees” for the covered procedure, plus any applicable Copayment for the covered procedure. Optional treatment does not apply when alternative choices are benefits. Optional procedures include:

— The use of a tooth-colored material when restoring a posterior tooth with a filling, inlay or onlay; and

— Units in a fixed partial denture (bridge) made of porcelain/ ceramic, which is not fused to and supported by underlying cast metal.

28. Porcelain crowns, porcelain fused to metal or resin with metal type crowns are not a benefit for children under 16 years of age. An allowance will be made for a resin crown. (See Limitation #27).


1324

6 A benefit for permanent teeth only.7 Includes after delivery adjustments and tissue conditioning,

if needed, for the first six months after placement, if the Enrollee continues to be eligible and the service is provided at the Contract Dentist’s facility where the denture was originally delivered.

8 Replacement is subject to a limitation requiring the existing denture to be 5+ years old.

9 Limited to 1 per denture during any 12 consecutive months.10 Replacement is subject to a limitation requiring the existing

bridge to be 5+ years old.11 Listed Copayment covers up to 24 months of active

orthodontic treatment excluding the services listed for D8999 (Start-up fee). Beyond 24 months of active treatment, an additional monthly fee of $75.00 applies.

12 In the event comprehensive orthodontic treatment is not required or is declined by the Enrollee, a fee of $25.00 will apply. The Enrollee is also responsible for any incurred orthodontic diagnostic record fees.

13 Includes adjustments and/or office visits up to 24 months. After 24 months, a monthly fee of $75.00 applies.

Star Dental Practice #0099798626 Lower Sacto Rd Ste 37B 209-951-8088 F/T 1 (HI, CH, SP, TA) U

Stockton Dental Group #0096651036 W Robinhood Dr Ste 104 209-956-9650 P/T 1 (SP)SUNNYVALEGentle Dental Sunnyvale #0096191639 Hollenbeck Ave 408-732-6931 F/T 1 P/T 2 (SP, TA, VI, HI, RU)Joon Ku Lee, DMD #009540990 W Fremont Ave Ste T 408-774-2828 F/T 1 (KO)Lora Costa, DDS #0091361286 Kifer Rd Ste 110 408-774-1200 P/T 1 (SP, TA, VI) U

Navjyot Panjrath, DDS #009135689 E Remington Dr Ste B 2 408-739-6521 F/T 1Sai Dental #0090321050 E El Camino Real 408-423-9197 F/T 1 (HI, PE)Smilesavers Dental #0090221214 Apollo Way Ste 402 408-737-0101 F/T 1Sunnyvale Dental Aesthetics #009015 1286 Kifer Rd Ste 105 408-736-8880 P/T 1 (CH, SP) U

Sunnyvale Family Dtl Care #008953990 W Fremont Ave Ste 0 408-739-8999 F/T 1 (SP)TRACYBrite Smiles Dentistry #0089071170 W 11th St 209-839-1600 F/T 1 (HI, SP)California Dental Group #0088723101 N Tracy Blvd 209-830-7473 F/T 1 U

Grantline Dental #0086872242 W Grant Line Rd Ste 102 209-832-2525 F/T 1 (HI, SP, TA, CH, TH) U

Paramjit Singh, DDS #0085384598 S Tracy Blvd Ste 150 209-221-6666 F/T 1 (HI, TA, SP) U

Smilecare-Tracy #0084542990 W Grant Line Rd 209-830-7797 F/T 5 P/T 3 (SP) U

Tracy Dental #0084282135 N Tracy Blvd 209-836-4950 F/T 1 P/T 2 (SP, TA) U

Tracy Smiles Dtl Grp #0082482600 S Tracy Blvd Ste 170 209-836-5441 P/T 1 (SP) U

University Dental #007823530 W Eaton Ave Ste L 209-839-8810 P/T 1 (SP, PE)TURLOCKHealthy Smile Dental #007289241 N Palm St 209-668-9300 P/T 2 (CH, HI, SP, TH)Monte Vista Dental #0072863212 W Monte Vista Ave 209-669-6500 P/T 1 (RU, SP, HI) U

UNION CITYShine Dental #00728434665 Alvarado Niles Rd 510-441-7645 F/T 1 (AR, HI, PE) U

Trinh Trac, DDS #00728233448 Alvarado Niles Rd 510-429-1178 F/T 1 (CA, VI, SP) U

VACAVILLEAlamo Family Dental Care #0072713000 Alamo Dr Ste 203 707-454-3888 F/T 1 P/T 3 U

Alamo Plaza Dental Office #005955810 Alamo Dr 707-469-8188 P/T 1 (SP, TA) U

All Smiles Dental #005532 1241 Alamo Dr Ste 11 707-447-8289 P/T 1 (SP) U

Bayside Dental #00553172 Peabody Rd 707-450-0732 F/T 1 (SP, TA, FR) U

Vacaville Dental Associates #005507412 Cernon St Ste A 707-452-0445 P/T 1 (PE, SP, TA) U

VALLEJOAccess Dental #0049273400 Sonoma Blvd 707-554-4000 F/T 1 P/T 4 (PE, SP, TA) U

Bayside Dental #0046532121 Redwood St Ste A 707-644-7600 P/T 1 (PE, SP, TA) U

Ec Dental Care #0044983315 Sonoma Blvd Ste 50 707-552-4800 F/T 1 (SP, TA) U

Julius Mosley II, DDS #0044972121 Redwood St Ste E 707-558-1660 F/T 1 U

Setty DDS Inc #003967480 Redwood St Ste 13 707-554-2600 P/T 1 (HI, TA, VI)Smilecare-Vallejo #003724133 Plaza Dr Ste R 707-557-6245 F/T 5 P/T 6 (SP)Vallejo Dental Associates #003718475 Redwood St Ste 30 707-643-1714 P/T 1 (PE, SP, TA)VISALIAAbc Dental Group #003503 2548 S Mooney Blvd 559-733-9797 F/T 2 (SP) U

Cosmetic Touch Dental Group #0029872634 W Walnut Ave 559-732-7224 P/T 1 (AM, SP)Visalia Dental #0027065344 W Cypress Ave Ste 101 559-635-4391 F/T 2 P/T 4 U

Visalia Family Dentistry #0022371644 W Caldwell Ave Ste A 559-740-0444 P/T 1 (TA, SP)WALNUT CREEKDaniel R Pestana, DDS #0019782255 Ygnacio Valy Rd Ste J2 925-945-8006 F/T 1 (SP) U

Dental Care Of Walnut Creek #0017041111 Civic Dr Ste 145 925-937-9017 P/T 2 (CH, HI, SP) U

Horizons Dental #0015041479 Ygnacio Valy Rd Ste 107 925-945-7977 P/T 2 (CA, SP) U

Mikhail Berdichevsky, DDS #001493120 La Casa Via # 105 # Via 925-933-9820 F/T 2 (RU) U

San Miguel Dental #0011591844 San Miguel Dr Ste 206 925-279-3326 F/T 1 P/T 2 (SP) U

Spring Dental #0011582987 N Main St 925-930-7770 F/T 1 (PE, SP) U

Tim Patel, DDS #0011571818 San Miguel Dr 925-945-7366 F/T 1 U

WATSONVILLECrossroads Dental #0008981951 Main St 831-761-9500 F/T 1 (SP) U

WEST SACRAMENTOAcme Dental #000893820 Westacre Rd 916-371-1500 F/T 1 P/T 1 (SP, PE) U

Dentistry Today #0007981001 Jefferson Blvd Ste 500 916-372-7022 F/T 1 U

South River Dental Group #0006692455 Jefferson Blvd Ste 130 916-372-8062 P/T 2 (SP) U

Vivian Fernandez, DDS #000594821 Jefferson Blvd 916-372-3368 F/T 1 (AM, RU, SP)WOODLANDCottonwood Dental Group #000286520 Cottonwood St Ste 4 530-669-6688 F/T 1 (SP, CH, HI, TA) U

Lincoln Dental #000221520 Cottonwood St Ste 11 530-661-9276 F/T 4 (SP) U

Yolo Dental Practice #000218520 Cottonwood St Ste 9 530-662-8100 F/T 2 (CA, SP, TA) U

YUBA CITYAccess Dental #000070940 Colusa Ave Ste A 530-755-9900 F/T 1 P/T 3 (SP)Melissa Lee, DDS #0000661215 Plumas St Ste 1901 530-751-7671 F/T 1 (CA, SP) U

ALAMEDABay View Dental #0329622181 Harbor Bay Pkwy 510-523-2188 F/T 1 Ca, Sp, Vi U

APTOSSam Christensen, DDS #0164097545 Soquel Dr Ste B 831-688-7878 F/T 1CLEARLAKELakeshore Dental Practice #00298615322 Lakeshore Dr Ste 104 707-994-6050 F/T 1 U

CLOVISMichael Ward, DDS #152901375 Bullard Ave Ste 3 559-298-7424 F/T 1 (SP) U

CONCORDDarryl Burke, DDS #1651013600 Concord Blvd 925-691-0238 F/T 2Robert Hlavac, DDS #1394012917 Salvio St Ste B 925-689-1772 F/T 1 (GE, SP) U

ELK GROVETerri Speed & Associates #0220969098 Laguna Main St Ste 4 916-691-1600 P/T 1 (SP) U

Terri Speed, DDS Inc #0220979381 E Stockton Blvd Ste 120 916-686-4212 P/T 2 (SP) U

EUREKAStephen Angeloff, DDS #0236923125 G St 707-445-4300 F/T 1 (SP)Victoria Place Dental Center #0029723144 Broadway Ste C1 707-443-9374 F/T 1 U

FAIRFIELDParkside Dental Team #0765011325 Travis Blvd Ste D 707-427-2222 F/T 3 (Sp) U

FOLSOMSummit Dental #15910125004 Blue Ravine Rd Ste 111 916-355-8400 F/T 1 (PE, SP, RU) U

FREEDOMFamily Dental Center #155701122 Thicket Ln 831-724-6000 F/T 1 (SP)FREMONTKamlesh Jinjuwadia, DDS #1353013500 Mowry Ave Ste A 510-796-1499 F/T 1 (SP)Mission Dental #00673339560 Stevenson Pl Ste 218 510-494-8856 F/T 1 (SP)Precious Dental Care #0107053200 Mowry Ave Ste A 510-790-7900 F/T 1FRESNOKimmer Young, DDS #0146321431 W Shaw Ave 559-229-5930 F/T 1Rachel Jack, DDS #0265734747 N 1st St Ste 113 559-225-4540 F/T 1 Sp U

Sidney Jackson, DDS #1615017433 N 1st St Ste 101 559-447-3003 F/T 1 (SP) U

Snr Dental #0141537472 N Fresno St Ste 201 559-438-8686 F/T 1Thomas Downing, DDS #0265704747 N 1st St Ste 113 559-225-4540 F/T 1 (SP) U

GRANITE BAYAdvanced Dental Care #0224166910 Douglas Blvd Ste F 916-780-7676 F/T 1 (SP, RU) U

MADERAKimmer Young, DDS #0105492401 W Cleveland Ave 559-673-4075 F/T 1 P/T 1 (AR, FR, SP) U

MILPITASAlexander Galang, DDS #391301830 Hillview Ct Ste 150 408-934-7676 F/T 1 (TA)Liberty Plaza Dental Center #0158071252 S Abel St 408-945-4444 P/T 2Vincent Liang, DDS #021680106 Dixon Rd 408-934-1200 F/T 1 (CA, CH) U

MODESTOAccord Dental #0324154120 Dale Rd Ste J6 209-543-9999 F/T 1 (HI, SP) U

MOUNTAIN VIEWParktown Dental Care #170301990 Bay St 650-968-4000 F/T 1 (Sp, Vi) U

OAKLANDGentle Dental #1670011624 Franklin St Ste 615 510-451-7881 F/T 1 P/T 4 (CA, SP)PACHECOPacheco Family Dentistry #145901218 Center Ave 925-671-9900 P/T 1 U

REDDINGEric R Waits, DMD #0210462115 Eureka Way 530-246-1142 F/T 1 (GE, TA)ROCKLINJeffrey Routsong, DDS #0327655800 Stanford Ranch Rd # 510 916-435-3060 F/T 1 (SP) U

ROSEVILLESierra College Dtl Practice #0006679290 Srra Colg Blvd Ste 300 916-788-8450 F/T 2 (SP, VI) U

SACRAMENTOA+ Dental #0239443307 Alta Arden Expy 916-974-1819 F/T 1 (GE, KO, SP)Adriane Scortia, DDS #1333014611 Freeport Blvd Ste 5 916-451-4432 F/T 1 (RO, RU)SAN JOSEBlossom Hill Family Dental #1624015058 Union Ave Ste A 408-559-8668 F/T 1 (VI) U

Daniel Thompson, DDS #2076015710 Cahalan Ave Ste 5A 408-281-0500 F/T 1Evergreen Valley Dental #0118644868 San Felipe Rd Ste 120 408-528-8303 F/T 1 (HI, VI)Ever-Smile Dental Care #0113182910 Stevens Crk Blvd # 208 408-296-9900 F/T 1 (HI, SP)Rosalinda Hopkins, DMD #0040596199B Santa Teresa Blvd 408-972-8077 F/T 1 (TA)SAN LEANDROCorey Jang, DDS #374301433 Estudillo Ave Ste 302 510-351-0930 F/T 1 (CH, TA) U

Margaret Yap, DDS #17600113770 Doolittle Dr 510-352-3918 F/T 1 (CH, SP, TA)SAN MATEODeepak Sachdev, DDS #0016521415 S El Camino Real 650-573-6500 P/T 1 (SP)SAN RAFAELMarin Dental Care #0103904050 Redwood Hwy Ste A 415-499-7700 F/T 1 P/T 1 (SP, CH, TA) U

SANTA CLARAColeman Family Dental #0299841341 Coleman Ave 408-844-9578 F/T 1 (TA)De La Vega Dental Corp #0142671210 Homestead Rd 408-260-7384 F/T 1 (SP, TA) U

Santa Clara Family Dental #0283962725 El Camino Real Ste 109 408-241-4111 F/T 3 (PE, SP)Thomas Puzin, DDS #260501545 Saratoga Ave Ste B 408-247-5442 F/T 1 (SP)STOCKTONM Luisa Bermudez, DMD #137801221 Tuxedo Ct Ste D 209-466-0254 F/T 1 (TA)SUNNYVALEPalm Bay Dental #0027091301 Snvl Saratoga Rd # 2 408-732-2112 F/T 1 (SP, VI) U

Stephen Fong, DDS #0C9501990 W Fremont Ave Ste S 408-736-4101 F/T 1TURLOCKColorado Family Dentistry #0046152150 Colorado Ave 209-668-9442 F/T 1 (SP)Delbon Dental #0236271060 Delbon Ave 209-667-2977 P/T 1 (AR, SP) U

VACAVILLEAlamo Dental #0214263057 Alamo Dr 707-448-8881 F/T 2 (TA, SP) U

Glenn Fung, DMD #019513885 Markham Ave 707-448-8851 F/T 1 (SP) U

VALLEJOTri-City Dental Vallejo #0228963630 Sonoma Blvd 707-643-1987 F/T 1 (SP) U

ACTONSoo Park, DDS #03113433342 Santiago Rd 661-269-4200 F/T 1AGOURA HILLSAgoura Dental #02209130313 Canwood St Ste 36 818-735-3800 F/T 1 (GE, PE, SP)Agoura Family Dental #02348229219 Canwood St Ste 250 818-991-2626 P/T 1 (PE, SP, TA) U

Sea Breeze Dental Care #00662929525 Canwood St Ste 200 818-991-9852 F/T 2 P/T 2 (AM, PE, RU, SP) U

ALHAMBRAAlhambra Family Dentistry #118001600 W Main St Ste 102 626-282-4119 F/T 1 (SP) U

Drs Lee and Yee #051601157 N Garfield Ave 626-284-5113 F/T 2 P/T 1 (CH, SP) U

Jin Zhang, DDS #0259391711 W Main St 626-308-1711 F/T 1Mohammad Dabbousi, DDS #000647401 N Garfield Ave Ste 5 626-570-0974 F/T 1 (AR, TA) U

Nadir Yazdani, DDS #0C0201747 S Garfield Ave 626-289-6815 F/T 2 (EI, SP)ALISO VIEJOAll Smile Dental Group #02649222912 Pacific Park Dr Ste A 949-716-6900 F/T 1 (CH, SP) U

Claire Cho, DDS #0038212 Mareblu Ste 200 949-831-8826 F/T 1 (KO, PE, SP, TA) U

Duong & Petchpud DDS #0331955 Journey Ste 250 949-360-1021 P/T 2 (PE, SP, TH, VI) U

ALTA LOMACarnelian Family Dentistry #1988016626 Carnelian St 909-987-4113 F/T 1 (Ch, Sp)Jia Lee, DDS #0049569320 Baseline Rd Ste E 909-989-5598 P/T 2ANAHEIM7 Day Dental #0137702265 W Lincoln Ave 714-491-8600 F/T 1 P/T 6 (CH, TA, SP, VI) U

Anaheim Community Dentistry #013480435 N State College Blvd 714-635-0855 P/T 1 (PE, SP, VI) U

Anaheim First Family Dental #2565011161 N Euclid St 714-999-5050 F/T 1 P/T 1 (SP)Anaheim Hills Dental Group #3C22015731 A-5701 Santa Ana Cyn Rd 714-998-2956 P/T 2 (SP)Anaheim Open 7 Days Dental #274701637 N Euclid St 714-772-2893 F/T 1 P/T 6 (AR, PE, TA) U

Bright Now! Dental #004784150 N State College Blvd 714-491-8441 F/T 6 P/T 13 (SP, VI) U

Ca Dental Group of N Anaheim #0086711221 N Euclid St 714-491-2732 P/T 1 (SP, VI) U

Care Dental #0210503203 W Ball Rd 714-995-3415 F/T 2 (VI) U

Charles Kimball, DDS #032294 522 N Magnolia Ave 714-828-1415 F/T 1 P/T 1 (SP, TA)Coastal Dental Care #007875922 S Euclid St 714-776-7015 F/T 1 P/T 2 (SP) U

Coastal Dental Care #0078762300 S Harbor Blvd 714-750-3030 F/T 1 P/T 1 (SP, VI) U

Danny Thomas, DDS #188001601 S Euclid St 714-778-0700 P/T 1 (RU, SP, VI)Dental Care of Anaheim #258301815 N Euclid St 714-758-0791 F/T 2 P/T 1 (SP, HI) U


Northern CaliforniaOffices (Closed)

Southern CaliforniaOffices (Open)

SCHEDULE BLIMITATIONS OF BENEFITS1. Full mouth x-rays are limited to one set every 24 consecutive

months and include any combination of periapicals, bitewings and/or panoramic film.

2. Bitewing x-rays are limited to not more than one series of four films in any six month period.

3. Diagnostic casts are limited to aid in diagnosis by the Contract Dentist for covered benefits.

4. If a biopsy is preauthorized by Delta Dental for an oral surgeon, then examination of the resulting biopsy specimen is covered under codes D0472, D0473 or D0474 and available at no additional cost.

5. Prophylaxis or periodontal maintenance is limited to two procedures each 12 month period.

6. Benefits for sealants include the application of sealants only to permanent first and second molars with no decay, with no restorations and with the occlusal surface intact, for first molars and second molars through age 15. Benefits for sealants do not include the repair or replacement of a sealant on any tooth within three years of its application.

7. A filling is a benefit for the removal of decay, for minor repairs of tooth structure or to replace a lost filling.

8. A crown is a benefit when there is insufficient tooth structure to support a filling or to replace an existing crown that is non-functional or non-restorable and meets the five year limitation (see Limitation #12).

9. A covered metallic inlay, onlay, crown or fixed partial denture (bridge) using base or noble metal is available for listed Copayment(s). If the Enrollee elects to have high noble metal used instead, the maximum additional cost of this material upgrade is $100.00 per tooth or pontic. For an indirectly fabricated post and core, the benefit is for base or noble metal. If the Enrollee elects to have a high noble metal indirectly fabricated post and core instead, the maximum additional cost of this material upgrade is $100.00 per tooth.

10. For molars, a covered crown or unit of a fixed partial denture (bridge) is a full cast metal restoration without porcelain or other tooth-colored material. If the Enrollee elects to have porcelain, porcelain-fused-to-metal, resin or resin-with-metal used instead, the maximum additional cost for this tooth-colored material upgrade is $150.00 per molar.

11. If a porcelain margin is also chosen by the Enrollee for a covered porcelain-fused-to-metal crown, the maximum additional cost for this laboratory upgrade is $75.00.

12. The replacement of an existing inlay, onlay, crown, fixed partial denture (bridge) or a removable full or partial denture is covered when:

a. The existing restoration/bridge/denture is no longer functional and cannot be made functional by repair or adjustment, and

(continued)

12 25


D5214 Mandibular partial denture — cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 7, 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $375.00

D5281 Removable unilateral partial denture — one piece cast metal (including clasps and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00

D5410 Adjust complete denture — maxillary 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5411 Adjust complete denture — mandibular 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5421 Adjust partial denture — maxillary 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5422 Adjust partial denture — mandibular 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5510 Repair broken complete denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D5520 Replace missing or broken teeth — complete denture (each tooth). . . . . . . . . . . . . . . . . . . . . . $15.00D5610 Repair resin denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5620 Repair cast framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D5630 Repair or replace broken clasp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5640 Replace broken teeth — per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15.00D5650 Add tooth to existing partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15.00D5660 Add clasp to existing partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D5710 Rebase complete maxillary denture 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5711 Rebase complete mandibular denture 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5720 Rebase maxillary partial denture 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5721 Rebase mandibular partial denture 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5730 Reline complete maxillary denture (chairside) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5731 Reline complete mandibular denture (chairside) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5740 Reline maxillary partial denture (chairside) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5741 Reline mandibular partial denture (chairside) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D5750 Reline complete maxillary denture (laboratory) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5751 Reline complete mandibular denture (laboratory) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5760 Reline maxillary partial denture (laboratory) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5761 Reline mandibular partial denture (laboratory) 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D5820 Interim partial denture (maxillary) — limited to initial placement of interim partial

denture/stayplate to replace extracted anterior teeth during healing 7 . . . . . . . . . . . . . . . . . . . $180.00D5821 Interim partial denture (mandibular) — limited to initial placement of interim partial

denture/stayplate to replace extracted anterior teeth during healing 7 . . . . . . . . . . . . . . . . . . . $180.00D5850 Tissue conditioning, maxillary 7, 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30.00D5851 Tissue conditioning, mandibular 7, 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30.00

D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS — Not Covered

D6000-D6199 VIII. IMPLANT SERVICES — Not Covered

D6200-D6999 IX PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge])

D6210 Pontic — cast high noble metal 5, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6211 Pontic — cast predominantly base metal 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6212 Pontic — cast noble metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6240 Pontic — porcelain fused to high noble metal 4, 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6241 Pontic — porcelain fused to predominantly base metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6242 Pontic — porcelain fused to noble metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6245 Pontic — porcelain/ceramic 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6250 Pontic — resin with high noble metal 4, 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6251 Pontic — resin with predominantly base metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6252 Pontic — resin with noble metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6545 Retainer — cast metal for resin bonded fixed prosthesis 4, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D6600 Inlay — porcelain/ceramic, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6601 Inlay — porcelain/ceramic, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6602 Inlay — cast high noble metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6603 Inlay — cast high noble metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6604 Inlay — cast predominantly base metal, two surfaces 2, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6605 Inlay — cast predominantly base metal, three or more surfaces 2, 10. . . . . . . . . . . . . . . . . . . . . OptionalD6606 Inlay — cast noble metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6607 Inlay — cast noble metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6608 Onlay — porcelain/ceramic, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6609 Onlay — porcelain/ceramic, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6610 Onlay — cast high noble metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6611 Onlay — cast high noble metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6612 Onlay — cast predominantly base metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6613 Onlay — cast predominantly base metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . OptionalD6614 Onlay — cast noble metal, two surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6615 Onlay — cast noble metal, three or more surfaces 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6720 Crown — resin with high noble metal 4, 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6721 Crown — resin with predominantly base metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6722 Crown — resin with noble metal 4, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D6740 Crown — porcelain/ceramic 2, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD6750 Crown — porcelain fused to high noble metal 4, 5, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6751 Crown — porcelain fused to predominantly base metal 4, 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6752 Crown — porcelain fused to noble metal 4, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D6780 Crown — ¾ cast high noble metal 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6781 Crown — ¾ cast predominantly base metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6782 Crown — ¾ cast noble metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6790 Crown — full cast high noble metal 5, 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6791 Crown — full cast predominantly base metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6792 Crown — full cast noble metal 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $240.00D6930 Recement fixed partial denture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D6940 Stress breaker 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated —

includes canal preparation 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $90.00D6972 Prefabricated post and core in addition to fixed partial denture retainer — base metal

post; includes canal preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D6973 Core buildup for retainer, including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00D6976 Each additional indirectly fabricated post — same tooth — includes canal

preparation 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $90.00D6977 Each additional prefabricated post — same tooth — base metal post; includes canal

preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D6980 Fixed partial denture repair, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00

D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERYIncludes preoperative and postoperative evaluations and treatment under a local anesthetic.D7111 Extraction, coronal remnants — deciduous tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $35.00D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) . . . . . . . . . . . . . . $35.00D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and

removal of bone and/or section of tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00

D7220 Removal of impacted tooth — soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00D7230 Removal of impacted tooth — partially bony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00D7240 Removal of impacted tooth — completely bony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D7241 Removal of impacted tooth — completely bony, with unusual surgical

complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D7250 Surgical removal of residual tooth roots (cutting procedure). . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00D7251 Coronectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150.00D7286 Biopsy of oral tissue — soft — does not include histopathologic examination or other

pathology laboratory procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10.00D7310 Alveoloplasty in conjunction with extractions — four or more teeth or tooth spaces,

per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D7311 Alveoloplasty in conjunction with extractions — one to three teeth or tooth spaces,

per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D7320 Alveoloplasty not in conjunction with extractions — four or more teeth or tooth

spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00D7321 Alveoloplasty not in conjunction with extractions — one to three teeth or tooth

spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00D7471 Removal of lateral exostosis (maxilla or mandible) — per site. . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D7510 Incision and drainage of abscess — intraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D7960 Frenulectomy (frenectomy or frenotomy) — separate procedure . . . . . . . . . . . . . . . . . . . . . . . . $25.00

D8000-D8999 XI. ORTHODONTICSD8070 Comprehensive orthodontic treatment of the transitional dentition — child or

adolescent to age 19 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,600.00D8080 Comprehensive orthodontic treatment of the adolescent dentition — adolescent to

age 19 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,600.00D8090 Comprehensive orthodontic treatment of the adult dentition — adults, including

dependent adult children age 19 and older 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,800.00D8660 Pre-orthodontic treatment visit — not to be charged with any other consultation

procedure(s) 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD8680 Orthodontic retention (removal of appliances, construction and placement of

retainers) 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD8999 Unspecified orthodontic procedure, by report — includes the START-UP FEE, which

includes initial examination, diagnosis, consultation and initial banding . . . . . . . . . . . . . . . . . . $350.00

D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICESD9110 Palliative (emergency) treatment of dental pain — minor procedure . . . . . . . . . . . . . . . . . . . . . $35.00D9211 Regional block anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9212 Trigeminal division block anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9215 Local anesthesia in conjunction with surgery procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9310 Consultation — diagnostic service provided by dentist or physician other than

requesting dentist or physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9430 Office visit for observation (during regularly scheduled hours) — no other services

performed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD9440 Office visit — after regularly scheduled hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00

Procedures not listed above are not covered, however, may be available at the Contract Dentist’s “filedfees.”

“Filed fees” means the Contract Dentist’s fees on file with Delta Dental. Questions regarding these feesshould be directed to Delta Dental’s Customer Service department at 800-422-4234.

FOOTNOTES1 An amalgam is the benefit.2 Optional is defined as any alternative procedure presented

by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the Limitations and Exclusions of the program. The applicable charge to the Enrollee is the difference between the Contract Dentist’s “filed fee” for the Optional procedure and the “filed fee” for the covered procedure, plus any applicable Copayment. “Filed fees” means the Contract Dentist’s fees on file with Delta Dental. Questions regarding the DeltaCare USA program should be directed to Delta Dental’s Customer Service department at 800-422-4234.

3 Replacement is subject to a limitation requiring the existing restoration to be 5+ years old.

4 Porcelain and other tooth-colored materials on molars are considered a material upgrade with a maximum additional charge to the Enrollee of $150.00.

5 Base or noble metal is the benefit. High noble metal (precious), if used, will be charged to the Enrollee at the additional maximum cost to the Enrollee of $100.00 per tooth. If an indirectly fabricated post and core is made of high noble metal, an additional fee up to $100.00 per tooth will be charged for the upgrade. This charge also applies to a titanium crown.

Dental Health Anaheim Hills #0251738295 E Monte Vista Rd Ste B 714-685-9197 P/T 2 (SP, HI, TA, KO, FR, GE, RU)Derrick Brown, DDS #021501853 N Harbor Blvd 714-535-2487 F/T 1Euclid Dental Center #0305511751 W Romneya Dr Ste D 714-772-3538 P/T 1 (SP, TA)Excel Dental #0214421602 N Lemon St 714-525-5558 F/T 1 (SP, VI, CH)Gentle Dental-Anaheim #0085352170 W Lincoln Ave 714-535-3933 F/T 1 P/T 1 (PE, RO, SP, VI) U

Grand Dental #0133373070 W Lincoln Ave Ste O 714-828-3028 F/T 1 (SP)Manhar Mistry DDSInc #1C7301420 S State College Blvd 714-772-0770 F/T 1 (SP)Maysoon Saeed, DDSInc #013160710 S Brookhurst St Ste K 714-758-0778 F/T 1 (AR, SP)Morgan Dental #0242342601 W Ball Rd Ste 101 714-995-4444 P/T 1Neeta Somani, DDSInc #0216901842 W Lincoln Ave Ste B 714-533-4321 F/T 1 (HI)Noemi Taguinod, Dental #026769408 S Beach Blvd Ste 113 714-816-0954 F/T 1 (SP, TA)Radiance Dental #0123895675 E La Palma Ave Ste 197 714-695-0593 P/T 1 (SP) U

Smile Select #3521018285 E Santa Ana Canyon Rd 714-974-5599 F/T 2 (SP)Smilecare-Anaheim #0022521112 N Magnolia Ave 714-828-1211 F/T 1 P/T 7 (SP)Smiles For Orange County #2350019672 Ball Rd 714-772-0102 F/T 1 (SP)State College Dental Group #003047330 N State College Blvd 105 714-772-5005 P/T 4 (SP, VI) U

Sunkist Dental Office #0140972500 E Ball Rd Ste 150 714-533-9670 P/T 1 (SP, HI) U

Universal Care Dental #1C03011814 W Lincoln Ave 714-780-5665 F/T 4 P/T 4 (SP, TA, VI) U

Village Dental #0273341210 S Brookhurst St 714-535-7500 F/T 1 P/T 1 (AR, SP) U

APPLE VALLEYApple Valley Dental Office #00868918245 Us Highway 18 Ste 4 760-242-2977 F/T 3 P/T 1Apple Valley Dtl Associates #00914720162 Us Highway 18 Ste L 760-946-1466 P/T 2 (SP, KO)Apple Valley Smiles #02288912218 Apple Vly Rd Blg1 110 760-300-3678 P/T 2 (SP) U

Desert Dental Group #02416519195 Outer Hwy 18 Ste 201 760-242-0796 F/T 2 P/T 1 (TA)Haisam Sayed, DDSInc #02893418805 Bear Valley Rd Ste 4 760-961-7001 F/T 1 (AR, SP)Parkway Dental Group #02323520258 Us Highway 18 Ste 400 760-646-8839 P/T 2 (SP) U

ARCADIAArcadia Dental Center #196501440 E Huntington Dr Ste 101 626-447-5126 F/T 1 P/T 1 (KO, PE, SP) U

Arcadia Dental Group #028125111 E Live Oak Ave 626-445-1181 F/T 2 P/T 1 (SP, CH, VI, CA, AM)Drs Cheng & Kim #0174831043 W Huntington Dr 626-445-9660 F/T 1 P/T 1 (CA, KO, SP) U

Jason Gee DDSInc #029181638 W Duarte Rd Ste 9 626-447-7877 F/T 1

Kai Wu, DDS Inc #011037906 S Baldwin Ave 626-462-9890 F/T 1 (SP, CH, JA, TA)Live Oak Dental #026090288 E Live Oak Ave Ste C 626-898-0008 P/T 1Marc Rojtman, DDS #021394301 W Huntington Dr 626-445-3550 F/T 1 (FR, SP)Santa Anita Dental Group #018884721 W Huntington Dr Ste B 626-574-1766 F/T 1 P/T 1 U

William Houston, DDS #38620125 N Santa Anita Ave Ste E 626-254-1948 F/T 1ARLETAOsborne Dental Office Inc #00285213205 Osborne St Ste F 818-890-2426 F/T 1 (SP) U

Sima Boostanfar, DMD #0002239069 1/2 Woodman Ave 818-893-8799 F/T 1 P/T 1 (SP, PE)Woodman Family Dentistry #1986018725 Woodman Ave 818-891-6670 F/T 1 (SP)ARROYO GRANDEJeffrey Williams, DDS #286501236 S Halcyon Rd 805-489-1495 F/T 1ARTESIADr Moy DDSInc #02959511747 South Street 562-865-3635 F/T 1 (CA, SP) U

Egari Dental Office #01326218011 Pioneer Blvd # C 562-402-4492 F/T 1 (PE, SP)Sarah Cupino, DMD #00073312146 South St Ste E 562-924-1007 F/T 1 (SP, TA) U

Sioe Hwa Ong DDSInc #11220117906 Pioneer Blvd Ste 100 562-860-9612 F/T 1 P/T 1 (SP, TA) U

AzusaAngela Hoffman, DDSInc #011613483 S Citrus Ave 626-966-3400 F/T 1 (RU, SP) U

Apple Dental #002012891 E Arrow Hwy Ste B 626-332-4788 F/T 1 (SP)Bright Now Dental/Azusa #033796810 E Alosta Ave 626-804-2144 P/T 5 (CH, SP) U

Canyon City Dental Care #017992706 N Azusa Ave 626-334-7310 F/T 1 (SP) U

James Ahn, DDSInc #012598315 E Gladstone St 626-969-6728 F/T 1 (SP) U

Noble Dental Office #022978590 E Foothill Blvd 626-969-1116 P/T 1 (HI, SP)BAKERSFIELD17th Street Dental Care #0280071621 17th St 661-631-0529 P/T 1 U

Bakersfield Dental Group #0121365120 Stockdale Hwy Ste D 661-324-5442 F/T 1 (SP)Bhaskar Joshi, DDSInc #0134852519 River Blvd 661-873-9632 F/T 1 (HI, SP)Bright Dental Care #0265081120 Calloway Dr Unit 400 661-588-2772 F/T 1 (KO, SP) U

Centennial Dental Clinic #020011201 China Grade Loop 661-393-4333 P/T 2 (AR, SP)Crown Dental #0265746300 White Ln Ste C 661-827-1100 F/T 1 (SP, VI) U

Dedicated Dental #0141469600 Rosedale Hwy 661-589-5248 F/T 1 P/T 1 (SP) U

Dedicated Dental #0141478200 Stockdale Hwy Ste M9 661-834-9042 F/T 2 P/T 1 (KO, SP) U

Dedicated Dental #0141523150 Panama Ln Ste H 661-396-0156 F/T 2 P/T 3 (RU, SP) U

Dedicated Dental Calif Ctr #0131573400 Wible Rd 661-835-8672 F/T 1 P/T 2 (SP) U

East Hills Family Dentistry #0209382600 Oswell St Ste F 661-871-4132 P/T 1 (SP, TA)F M Hanna, DDS #0172903809 San Dimas St Ste A 661-322-7696 P/T 1 (AR, SP)G Street Family Dental #1C56012611 G St 661-859-0192 F/T 1Home Care Dental #0200145917 Niles St # 3 661-366-6527 F/T 1 P/T 1Mercy Plaza Dental Group #020863500 Old River Rd Ste 225 661-663-0109 F/T 2 (AM, GE, RU, SP)Millennium Dental Center #0330921830 28th St 661-326-8536 P/T 2 (AR, SP)River Lakes Dental Group #0129869510 Hageman Rd Ste B 661-829-2700 P/T 1 (VI) U

Robert Redelsperger, DDS #013335 2106 20th St 661-324-6053 F/T 1 (SP)Sian Poh, DDS #1641012721 H St 661-324-9709 F/T 1 (CH, SP)Smilecare-Bakersfield #0029732750 Ming Ave 661-396-1701 F/T 4 P/T 1 (SP) U

BALDWIN PARKBaldwin Park Family Dental #02989813020 Francisquito Ave Ste 7 626-962-9474 F/T 1 (SP, KO)David Kutner, DMD #05780113734 Ramona Blvd 626-960-6616 F/T 1 (KO, SP) U

Impressive Dental Care #03341614510 Towne Center Drive F2 626-851-4444 P/T 1 U

Prakash Patel, DDS #0003134138 Maine Ave Ste N3 626-960-6395 P/T 1 (SP)Ramona Family Dentistry #00398814325 Ramona Blvd 626-962-6814 F/T 1 (KO, SP) U

San Jose Young Dental #03135714514 Ramona Blvd Ste 1 626-337-4700 F/T 1 (KO, SP) U

West Coast Dental #0190014000 La Rica Ave Ste D 626-430-9171 F/T 1 P/T 1 (SP, CH) U

BANNINGDental Works #0042056350 W Ramsey St Ste A 951-769-0466 F/T 1 (SP)Pass Dental Group #0311544240 W Ramsey St 951-849-4484 P/T 1BARSTOWDr Salman Dental #023375927 Armony Rd 760-252-4488 P/T 1 (AR, SP)Procare Dental Grp #0239001232 E Main St 760-256-1189 F/T 1 (TA, SP) U

BEAUMONTBeaumont Dental Group #014131 930 Beaumont Ave 951-845-2200 F/T 1 P/T 2 (FR, HI, SP) U

Beaumont Smiles Dental Group #0269121620 E 2Nd St Ste A 951-769-9131 P/T 1 U

BELLBell Dental! #0134376633 Atlantic Ave 323-773-1000 F/T 4 P/T 6 (SP) U

Bell Plaza Dental Center #0214786343 Atlantic Ave Ste C 323-771-7226 F/T 1 (PE, SP) U

Dentalville #0233095021 Florence Ave 323-560-1508 P/T 2 (SP) U

Dr Desai-Gage Family Dental #0131444127 Gage Ave 323-773-2931 F/T 2 (Sp) U

Kamran Hakim, DDS #0122926334 Atlantic Ave 323-560-3646 P/T 1 (SP, PE)

La Familia Dental Group #0236464203 Gage Ave 323-312-0500 P/T 1St. Mary & St. George Dtl Ctr #0268566905 1/2 Atlantic Ave 323-773-5029 F/T 1 (PE, RU, SP) U

BELL GARDENSJin Wei Chu, DDS #3720016526 Eastern Ave 323-771-3949 F/T 2 (CH, SP)Marketplace Dental Office #3284016815 Eastern Ave Ste A1 323-560-2595 P/T 1 (SP) U

BELLFLOWERBellflower Dental #01992317615 Lakewood Blvd 562-408-1447 F/T 2 P/T 1 (SP)Bellflower Family Dtl Service #35970117019 Bellflower Blvd 562-866-9739 F/T 1 (SP, HI)California Dental Group #02382410106 Alondra Blvd # A 562-867-5117 P/T 1 (SP, KO)Crown Dental #0192339202 Alondra Blvd 562-866-8444 P/T 1 (SP, KO) U

Gerald Sandarg, DDS #18550117024 Clark Ave Ste C 562-925-7436 F/T 1 (SP)John Lim, DMD #32930110120 Alondra Blvd 562-920-6644 F/T 1 (SP) U

Michael Ahn, DDS #02149816106 Bellflower Blvd 562-920-9220 F/T 1 (KO, SP)Rosecrans Dental Group #0032089222 Rosecrans Ave 562-272-0222 P/T 6 (SP, VI) U

Smile Center Dental Group #01063416537 Bellflower Blvd Ste B 562-866-7073 P/T 1 (Pe, Sp) U

Smilecare-Bellflower #00448117240 Downey Ave 562-531-0221 P/T 4 (SP)Somerset Dental #0175309426 Somerset Blvd 562-925-3735 P/T 1 (CH, SP) U

Universal Care Dental #1C090117660 Lakewood Blvd 562-461-1180 F/T 3 P/T 5 (SP, TA, VI) U

BEVERLY HILLSBedford Dental Group #013340432 N Bedford Dr 310-278-0600 F/T 1 (GE, PE, SP) U

Bedford Dental Group #018257432 N Bedford Dr 310-278-2424 F/T 1 (PE, GE) U

Beverly Hills Cosmetic Dental #0054839400 Brighton Way Ste 309 310-273-7397 F/T 1 P/T 2 (RU, SP)Clay Loveday, DMD #017520416 N Bedford Dr Ste 209 310-248-3607 F/T 1 U

David Abri DDSInc #01989150 N La Cienega Blvd Ste 217 310-275-0032 P/T 1 (PE, SP) U

Dental Group of Beverly Hills #146801250 N Robertson Blvd Ste 412 310-271-3003 F/T 1 P/T 1 (AM, PE, SP) U

Dental Group of Beverly Hills #00354599 N La Cienega Blvd Ste 300 310-289-1818 P/T 1 (SP, TA) U

Jjp Dental #021771435 N Bedford Dr Ste 108 310-276-2009 F/T 1Kambiz Kashfian, DDS #30500150 N La Cienega Blvd Ste 206 310-659-7949 F/T 1Naomeh Mashhood, DDS #0165688500 Wilshire Blvd Ste 602 310-289-1101 P/T 1 U

Pacific Dental Care #3630019025 Wilshire Blvd Ste 315 310-274-7485 F/T 1 P/T 1 (SP) U

Roxbury Dental #0054609100 Wilshire Blvd Ste 363W 310-553-8188 F/T 1 U

Smile Angels of Beverly Hills #0263478500 Wilshire Blvd Ste 709 310-201-9001 F/T 1 U

Steven Goldy and Assoc #255201416 N Bedford Dr Ste 409 310-550-1511 F/T 1 (SP)BLOOMINGTONJack Ackerman, DDS #370001993 W Valley Blvd Ste 103 909-877-3660 F/T 1 (SP) U

BONITABonita Family Dental #0132834424 Bonita Rd 619-479-8703 F/T 2 P/T 2 (SP, TA, RU, HI)BREABerry Imperial Dental Group #1C4801649 W Imperial Hwy Ste H 714-529-1232 F/T 1 P/T 1 (CH, SP, HI) U

Brea Dental Arts #025702710 N Brea Blvd Ste E 714-529-8558 P/T 2 (SP, CA, CH)Brea Dental Group #007310503 E Imperial Hwy 714-672-9000 F/T 1 P/T 1 (AR, SP, VI) U

Brea Dentistry #022863782 N Brea Blvd 714-257-0330 P/T 1 U

Harin Shodhan, DDS #026114936 E Imperial Hwy 714-990-4911 F/T 1 (SP) U

Imperial Dental Care #3C1501200 E Imperial Hwy 714-671-9999 F/T 1 P/T 1 (FR, SP, HI, VI)Sheena Bhatia, DDS #025689151 S Kraemer Blvd Ste C1 714-257-9200 F/T 1 (SP, HI) U

William Lou, DDS #152701552 E Lambert Rd 714-990-3344 F/T 1BUENA PARKForoutan Dental Corporation #0123538951 Knott Ave Ste L 714-826-4181 F/T 2 (PE, SP)Mona Fahmy, DDS #0016878402 Commonwealth Ave 714-739-2051 F/T 1 (AR, FR, SP, VI)P Dholakiya & Associates DDS #0299697011 Orangethorpe Ave # 100 714-994-4482 P/T 2 (HI, SP) U

Plaza Dental Care #0156608575 Knott Ave Ste A 714-761-8575 F/T 1 (KO, SP) U

St Therese Family Dentistry #1570016891 La Palma Ave 714-994-6911 F/T 1 (TA)Valley View Dental #02329810102 Valley View St 714-229-4898 P/T 1 (SP, HI, GE, RU) U

West Coast Dental #0146318381 La Palma Ave 714-228-9990 P/T 3 (SP) U

BURBANKBoyajian/ Bardakjian, DDS #0246603808 W Riverside Dr Ste 307 818-861-7840 F/T 2 U

Burbank Village Dentistry #017970928 N S F Blvd Ste E 818-841-8607 P/T 1 (RU, SP) U

Burbank/Glendale Dental Group #013523500 E Olive Ave Ste E430 818-567-4662 P/T 2 (PE, AM, SP) U

Burbank-Glendale Dental Group #013438216 E Alameda Ave 818-848-3026 P/T 1 (AM, SP, TA, PE, RU) U

Castle Dental Center #015675140 N Victory Blvd Ste 101 818-841-1634 F/T 4 P/T 8 (SP) U

Empire Dental Group #0115281635 N Victory Pl 818-565-0057 F/T 1 P/T 1 (AM, PE, SP) U

Harold A Lubick, DDS, MD #022119500 E Olive Ave Ste 440 818-848-5591 F/T 1 U

Hi Care Dental #017782354 E Angeleno Ave 818-846-4206 F/T 1John Yekikian, DDS #2360012601 W Alameda Ave Ste 406 818-843-7841 F/T 1 (AM, SP)Louis Mo, DDS #011035500 E Olive Ave Ste 460 818-846-3181 F/T 1 (SP) U

Mylene Nguyen, DDS #0318582720 W Magnolia Blvd 818-842-4879 P/T 1


1126

D0100-D0999 DIAGNOSTICD0120 Periodic oral evaluation — established patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0140 Limited oral evaluation — problem focused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0145 Oral evaluation for a patient under three years of age and counseling with

primary caregiver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0150 Comprehensive oral evaluation — new or established patient . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0160 Detailed and extensive oral evaluation — problem focused, by report . . . . . . . . . . . . . . . . . . . No CostD0170 Re-evaluation — limited, problem focused (established patient; not post-operative visit) . . . No CostD0180 Comprehensive periodontal evaluation — new or established patient . . . . . . . . . . . . . . . . . . . No CostD0210 Intraoral radiographs — complete series (including bitewings) — limited to 1 series every 24 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0220 Intraoral — periapical first film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0230 Intraoral — periapical each additional film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0240 Intraoral — occlusal film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0270 Bitewing radiograph — single film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0272 Bitewings radiographs — two films. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0273 Bitewings radiographs — three films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0274 Bitewings radiographs — four films — limited to 1 series every 6 months . . . . . . . . . . . . . . . No CostD0330 Panoramic film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0460 Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0470 Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0472 Accession of tissue, gross examination, preparation and transmission of written report . . . . . No CostD0473 Accession of tissue, gross and microscopic examination, preparation and transmission of

written report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD0474 Accession of tissue, gross and microscopic examination, including assessment of surgical

margins for presence of disease, preparation and transmission of written report . . . . . . . . . . . No CostD0999 Unspecified diagnostic procedure, by report — includes office visit, per visit (in addition

to other services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10.00

D1000-D1999 II. PREVENTIVED1110 Prophylaxis cleaning — adult — 2 per 12 month period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD1110 Additional prophylaxis cleaning — adult (within the 6 month period) . . . . . . . . . . . . . . . . . . . . $27.00D1120 Prophylaxis cleaning — child — 2 per 12 month period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD1120 Additional prophylaxis cleaning — child (within the 6 month period) . . . . . . . . . . . . . . . . . . . . $27.00D1203 Topical application of fluoride — child — to age 19; 2 per 12 month period . . . . . . . . . . . . . . No CostD1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk

patients — child to age 19; 2 per 12 month period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD1330 Oral hygiene instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No CostD1351 Sealant — per tooth — limited to permanent molars through age 15 . . . . . . . . . . . . . . . . . . . $15.00D1352 Preventive resin restoration — per tooth — limited to permanent molars through age 15 . . . $15.00D1510 Space maintainer — fixed — unilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $65.00D1515 Space maintainer — fixed — bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $65.00D1520 Space maintainer — removable — unilateral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $65.00D1525 Space maintainer — removable — bilateral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $65.00D1550 Re-cementation of space maintainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D1555 Removal of fixed space maintainer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00

D2000-D2999 III. RESTORATIVEIncludes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures.D2140 Amalgam — one surface, primary or permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $27.00D2150 Amalgam — two surfaces, primary or permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $32.00D2160 Amalgam — three surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $37.00D2161 Amalgam — four or more surfaces, primary or permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D2330 Resin-based composite — one surface, anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00D2331 Resin-based composite — two surfaces, anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $80.00D2332 Resin-based composite — three surfaces, anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $80.00D2335 Resin-based composite — four or more surfaces or involving incisal angle (anterior) . . . . . . . $80.00D2390 Resin-based composite crown, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D2391 Resin-based composite — one surface, posterior 1, 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2392 Resin-based composite — two surfaces, posterior 1, 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2393 Resin-based composite — three surfaces, posterior 1, 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2394 Resin-based composite — four or more surfaces, posterior 1, 2 . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2510 Inlay — metallic — one surface 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2520 Inlay — metallic — two surfaces 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2530 Inlay — metallic — three or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2542 Onlay — metallic — two surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2543 Onlay — metallic — three surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2544 Onlay — metallic — four or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2610 Inlay — porcelain/ceramic — one surface 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2620 Inlay — porcelain/ceramic — two surfaces 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2630 Inlay — porcelain/ceramic — three or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2642 Onlay — porcelain/ceramic — two surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2643 Onlay — porcelain/ceramic — three surfaces 2, 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2644 Onlay — porcelain/ceramic — four or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2650 Inlay — resin-based composite — one surface 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2651 Inlay — resin-based composite — two surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2652 Inlay — resin-based composite — three or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2662 Onlay — resin-based composite — two surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2663 Onlay — resin-based composite — three surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2664 Onlay — resin-based composite — four or more surfaces 2, 3 . . . . . . . . . . . . . . . . . . . . . . . . . . OptionalD2710 Crown — resin-based composite (indirect) 3, 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $125.00D2712 Crown — ¾ resin-based composite (indirect) 3, 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $125.00D2720 Crown — resin with high noble metal 3, 4, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D2721 Crown — resin with predominantly base metal 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D2722 Crown — resin with noble metal 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180.00D2740 Crown — porcelain/ceramic substrate 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00

D2750 Crown — porcelain fused to high noble metal 3, 4, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D2751 Crown — porcelain fused to predominantly base metal 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D2752 Crown — porcelain fused to noble metal 3, 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D2780 Crown — ¾ cast high noble metal 3, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2781 Crown — ¾ cast predominantly base metal 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2782 Crown — ¾ cast noble metal 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2790 Crown — full cast high noble metal 3, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2791 Crown — full cast predominantly base metal 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2792 Crown — full cast noble metal 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D2794 Crown — titanium 3, 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $275.00D2910 Recement inlay, onlay or partial coverage restoration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D2915 Recement cast or prefabricated post and core. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D2920 Recement crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00D2930 Prefabricated stainless steel crown — primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D2931 Prefabricated stainless steel crown — permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D2932 Prefabricated resin crown — anterior primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00D2933 Prefabricated stainless steel crown with resin window — anterior primary tooth . . . . . . . . . . $60.00D2940 Protective restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15.00D2950 Core buildup, including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00D2951 Pin retention — per tooth, in addition to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00D2952 Post and core in addition to crown, indirectly fabricated — includes canal preparation 5 . . . . $90.00D2953 Each additional indirectly fabricated post — same tooth — includes canal preparation 5 . . . . $90.00D2954 Prefabricated post and core in addition to crown — base metal post; includes canal

preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D2957 Each additional prefabricated post — same tooth — base metal post; includes canal

preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D2970 Temporary crown (fractured tooth) — palliative treatment only . . . . . . . . . . . . . . . . . . . . . . . . . No CostD2980 Crown repair, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00

D3000-D3999 IV. ENDODONTICSD3110 Pulp cap — direct (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $12.00D3120 Pulp cap — indirect (excluding final restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $12.00D3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to

the dentinocemental junction and application of medicament . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D3221 Pulpal debridement, primary and permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D3222 Partial pulpotomy for apexogenesis — permanent tooth with incomplete root development. . . . . . $45.00D3230 Pulpal therapy (resorbable filling) — anterior, primary tooth (excluding final restoration). . . . . $45.00D3240 Pulpal therapy (resorbable filling) — posterior, primary tooth (excluding final

restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $45.00D3310 Root canal — endodontic therapy, anterior tooth (excluding final restoration) 6 . . . . . . . . . . . . $150.00D3320 Root canal — endodontic therapy, bicuspid tooth (excluding final restoration) 6 . . . . . . . . . . . . $200.00D3330 Root canal — endodontic therapy, molar (excluding final restoration) 6 . . . . . . . . . . . . . . . . . . . $250.00D3346 Retreatment of previous root canal therapy — anterior 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D3347 Retreatment of previous root canal therapy — bicuspid 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D3348 Retreatment of previous root canal therapy — molar 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300.00D3351 Apexification/recalcification — initial visit (apical closure/calcific repair of

perforations, root resorption, etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.00D3410 Apicoectomy/periradicular surgery — anterior 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D3421 Apicoectomy/periradicular surgery — bicuspid (first root) 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D3425 Apicoectomy/periradicular surgery — molar (first root) 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D3426 Apicoectomy/periradicular surgery (each additional root) 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D3430 Retrograde filling — per root 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D3450 Root amputation, per root — not covered in conjunction with a hemisection 6. . . . . . . . . . . . . $50.00

D4000-D4999 V. PERIODONTICSIncludes preoperative and postoperative evaluations and treatment under a local anesthetic.D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or tooth bounded

spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00D4211 Gingivectomy or gingivoplasty — one to three contiguous teeth or tooth bounded

spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D4240 Gingival flap procedure, including root planing — four or more contiguous teeth or

tooth bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D4241 Gingival flap procedure, including root planing — one to three contiguous teeth or tooth

bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250.00D4260 Osseous surgery (including flap entry and closure) — four or more contiguous teeth

or tooth bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400.00D4261 Osseous surgery (including flap entry and closure) — one to three contiguous teeth or

tooth bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400.00D4341 Periodontal scaling and root planing — four or more teeth per quadrant — limited to 5

quadrants during any 12 consecutive months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D4342 Periodontal scaling and root planing — one to three teeth per quadrant — limited to 5

quadrants during any 12 consecutive months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis — limited

to 1 treatment in any 12 consecutive months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15.00D4910 Periodontal maintenance — limited to 2 treatments each 12 month period . . . . . . . . . . . . . . . $15.00

D5000-D5899 VI. PROSTHODONTICS (removable)D5110 Complete denture — maxillary 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.00D5120 Complete denture — mandibular 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.00D5130 Immediate denture — maxillary 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $450.00D5140 Immediate denture — mandibular 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $450.00D5211 Maxillary partial denture — resin base (including any conventional clasps, rests and

teeth) 7, 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300.00D5212 Mandibular partial denture — resin base (including any conventional clasps, rests and

teeth) 7, 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300.00D5213 Maxillary partial denture — cast metal framework with resin denture bases (including

any conventional clasps, rests and teeth) 7, 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $375.00

Schedule A Description of Benefits and CopaymentsThe benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2011 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.


Rene Ghotanian, DDS #0C4301500 E Olive Ave Ste 250 818-846-2600 F/T 1 P/T 1 (SP, AM)San Gabriel Summit Dental #000082255 E Orange Grove Ave Ste B 818-557-0996 F/T 1 (SP, TA)Toluca Lake Dental #0129343808 W Riverside Dr Ste 408 818-842-4019 F/T 1 (AM, SP, TA, PE) U

Vigen Alikhanian, DDS #0220623927 W Burbank Blvd 818-845-0900 F/T 1 (SP, RU, AM)Vineland Dental Practice #01173910970 Sherman Way Ste 102 818-565-0001 F/T 1 (KO, SP) U

CALABASASCalabasas Dental Group #35650126500 Agoura Rd Ste 115 818-871-0680 F/T 1 (PE, SP) U

CALEXICOCalexico Family Dentistry #024280400 Mary Ave 760-357-6409 P/T 1 (SP) U

Calexico Family Dentistry #0242822300 N Imperial Ave Ste E 760-357-1632 P/T 2 (SP) U

CAMARILLOCamarillo Dental Group #1987012380 Las Posas Rd Ste A D 805-388-9110 F/T 1 P/T 1 (SP) U

Douglas R Dill, DDS #0288992107 Pickwick Dr 805-445-1333 F/T 1 (SP) U

Farid Sehati, DDS #285401484 Mobil Ave Ste 33 805-482-9568 F/T 1 (PE, SP) U

Las Posas Dental Care #0031183901 Las Posas Rd Ste 209 805-383-6745 F/T 1 (CH, SP)Mission Oaks Dental Group #0172914900 Verdugo Way Ste A 805-484-7277 P/T 2 (SP) U

Palm Dental Care #0081852177 Ventura Blvd 805-388-1048 P/T 3 (JA, PE, SP, TA)R Trent/Gina Torgersen, DDS #018205484 Mobil Ave Ste 31 805-484-1221 F/T 2 (SP) U

Stars Dental Inc #0252221727 E Daily Dr Ste H 805-764-0222 F/T 1 (PE, SP) U

CANOGA PARKAllure Dental #0224178358 Topanga Canyon Blvd 818-348-8400 F/T 1 (AM, SP)Cosmeticare #02793721123 Victory Blvd 818-888-2700 P/T 1Kishore Shah, DDS #37540121001 13 Sherman Way 818-346-7032 P/T 2 (SP, TA) U

Marjan Garmestani, DDS #01724322030 Sherman Way Ste 317 818-610-2007 F/T 1 (PE, SP) U

Omega Dental Group #02557221712 Sherman Way 818-883-6634 F/T 1 (HE, PE, SP) U

Pary Afrashteh, DDS #3627017259 Owensmouth Ave 818-999-9900 F/T 1 (FR, SP, PE)Sheldon Springer, DDS #02316522030 Sherman Way Ste 204 818-716-5512 F/T 1 (SP) U

Sinai Dental Clinic #0028587257 Vassar Ave Ste 203 818-251-9794 F/T 1 (SP, PE, TR)Valley Circle Family Dental #02147923727 Roscoe Blvd 818-888-8824 P/T 1 (PE, TA) U

Warner Dental Care #02507121632 Sherman Way 818-999-6979 F/T 1West Valley Dental #2C48016543 Topanga Canyon Blvd 818-883-7979 P/T 1 (SP)White Smile Dental Group #00362422030 Sherman Way Ste 202 818-887-0260 P/T 2 (SP, PE, TA) U

CANYON COUNTRYAnna Liberman, DDS #14660118507 Soledad Canyon Rd 661-252-0020 F/T 2 (RU, SP)

Smiles Dental Group #03124018520 Soledad Canyon Rd 661-252-2800 P/T 1 (AM, RU, SP) U

CARLSBADCarlsbad Forum Dental #0269311905 Calle Barcelona Ste 229 760-479-0971 P/T 1 (AR) U

Carlsbad Open 7 Days Dental #0C88015814 Van Allen Way Ste 220 760-918-9000 F/T 1 (SP)Gateway Dental Group #0295162635 Gateway Rd Ste 101 760-431-8112 P/T 2 (SP) U

Gentle Dental Carlsbad #0300352620 El Camino Real Ste A 760-720-0966 F/T 2 P/T 1 (TA) U

Plaza Family Dental #0219182630 El Camino Real 760-434-1761 P/T 1 (SP) U

CARSONA1 Care Dental Center #023873602 W Sepulveda Blvd 310-830-3338 P/T 1 (SP, KO) U

Care Dental Center #01459523517 Main St Ste 106 310-513-0222 P/T 2 (SP, PE) U

Carson Dental Care #022146240 W Carson St 310-549-5580 F/T 1 P/T 1 (SP, TA)Family Dental Center #36370122813 Figueroa St 310-549-3717 F/T 1 (AR, SP)Great Choice Community Dental #032945247 W Carson St 310-847-7077 P/T 1 U

Hyacinth Ezeani, DDS #01486120763 Avalon Blvd 310-719-1865 P/T 1 (Sp) U

Island Dental #016934301 W Carson St 310-787-7053 F/T 1 (SP)Jaubin Nguyen, DDS #0123431754 E Carson St 310-518-7068 F/T 1 (SP, VI)Judina Morales, DDS #02465820401 Avalon Blvd Ste A 310-217-1507 F/T 1 (SP)Leticia Tolentino, DMD Inc #013256860 E Carson St Ste 106 310-522-9769 F/T 2 P/T 1 (TA) U

Randolph Lum, DDS #00254521847 Avalon Blvd 310-549-9710 F/T 1 (SP) U

Smilecare-Del Amo #003953550 E Del Amo Blvd 310-515-5672 P/T 3 U

CASTAICCastaic Dental Center #38540131886 Castaic Rd 661-257-2300 F/T 1 P/T 1 (CH, JA, AM, SP) U

Enitan Ibrahim, DDS #02712927947 Sloan Canyon Rd 661-294-3700 F/T 1Hasley Canyon Dental Group #01235629655 The Old Rd 661-702-8338 P/T 1 (PE, SP) U

CATHEDRAL CITYGentry Plaza Dental Care #1C350168555 Ramon Rd Ste D102 760-202-1171 F/T 1 (SP)Palm Dentistry #02962268487 E Palm Canyon Dr Ste 1 760-328-6208 F/T 2 (SP, TA) U

CerritosBloomfield Dental Center #18430112657 166th St 562-926-6502 F/T 1 (AR, SP) U

Cerritos Dental Center #03367111135 183Rd St 562-804-2296 P/T 1 (SP, TA) U

Cerritos Towne Ctr Dentistry #03309617550 Bloomfield Ave Ste C 562-809-4464 P/T 2 (CH, KO, SP) U

Eastern Dental Family Care #00561111466 South St 562-402-8166 F/T 1 (KO, SP, TA) U

Paul Kim, DMD #01321011900 South St Ste 122 562-809-6177 F/T 2 (SP, KO) U

CHATSWORTHDevonshire Plaza Dental Group #28410110230 Canoga Ave 818-341-8400 F/T 1Future Dental Care #02786410242 Canoga Ave 818-882-5252 P/T 1 (SP)Genuine Dental Care #01380410233 Topanga Canyon Blvd 818-772-5187 P/T 1 U

CHINOAnthony Kavorinos, DDS #03170112604 Central Ave 909-591-1745 F/T 1 P/T 1Brandon Chiu, DDS #02210813768 Roswell Ave Ste 211 909-590-8255 F/T 1 P/T 1Bright Smile Dental Care #01655412345 Mountain Ave Ste O 909-364-1330 F/T 1 (HI, SP) U

Chino Smiles Dental Group #0268526961 Schaefer Ave 909-590-0640 P/T 2 (SP) U

Family Dental Center #3676015436 Riverside Dr 909-465-5551 F/T 1 (SP)Galvan Family Dentistry Inc #0023374514 Philadelphia St Ste A 909-465-1016 P/T 1 (SP, TA) U

Group Dental Center Inc #0130235480 Philadelphia St Ste D 909-464-2399 F/T 1 (CH, SP)Smilecare-Chino #00396812233 Central Ave 909-628-0208 F/T 4 P/T 7 (SP) U

Upland Dental and Ortho #01459614335 Pipeline Ave Ste A 909-902-0800 P/T 2 (SP, CH, CA) U

William Valdez, DDS #3274014129 Riverside Dr 909-591-9211 F/T 1 (SP) U

CHINO HILLSChino Hills Dental Group #0031173410 Grand Ave Ste F 909-364-0001 F/T 2 P/T 1 (SP) U

Chino Hills Dental Office #0047652983 Chino Ave Ste A5 909-628-7000 F/T 1 (KO, SP)Dental Care Of Chino Hills #0318293280 Chino Hills Pkwy Ste 4 909-606-9907 P/T 1 (HI, SP, TA) U

Dentistry By Dr Doshi & Assoc #0195162140 Grand Ave Ste 265 909-364-9600 P/T 1 (HI) U

Pine Center Dental Group #0291765771 Pine Ave Ste S 909-597-2477 F/T 3 (SP, PE)Smile Savvy Dental Care #00567414676 Pipeline Ave Ste Q 909-393-3180 F/T 1 (TA, SP, KO, VI, TH)Tina Cho, DMD #02928014270 Chino Hills Pkwy 909-590-2229 P/T 1 (SP, KO)CHULA VISTABonita Smiles Dentistry #0182041558 E H St Ste B 619-421-9070 F/T 2 (FR, PE, SP) U

California Smiles #024548215 3rd Ave 619-427-7070 F/T 3 (SP, VI)Carmen Denise Maroon Lopez, DDS #0304172648 Main St Ste A 619-423-5200 F/T 1 (SP, TA) U

Dental Check Up #0120431010 Broadway Ste 5 619-422-0800 P/T 1 (SP)Gentle Dental Chula Vista #0C1801345 F St Ste 140 619-476-1001 F/T 1 P/T 2 (TA)Gentle Dental Chula Vista #003157301 3rd Ave 619-476-1444 F/T 1 P/T 1 (HI, SP)Maria Luisa Vales, DMD #00610388 E Bonita Rd Ste F 619-427-2646 F/T 1 (TA)Maria Zuniga, DDS Inc #011788985 Broadway Ste E 619-422-3473 F/T 1 (SP)Meigs Family Dental #0267761040 Tierra Del Rey Ste 209 619-656-9713 F/T 1 (SP)

Otay Lakes Dental Care #018811945 Otay Lakes Rd Ste H 619-397-5888 F/T 1 (TA) U

Palomar Dental Group #008781664 Palomar St Ste 1103 619-429-3948 F/T 1 P/T 1 (SP, VI)Perfecta Dental Group #012721314 Palomar St 619-498-3888 F/T 2 (CH, SP, VI)Smile Design Center #017111232 3rd Ave 619-827-0770 P/T 1 (SP, TA) U

Smile San Diego #031635585 Telegraph Canyon Rd 619-421-7010 F/T 3 P/T 1Smilecare-Chula Vista #004078510 Broadway Ste 4 5 619-476-9400 F/T 3 P/T 2 (SP) U

So. Bay Chula Vista Fam Dtl #005736290 Landis Ave Ste A B 619-691-0121 P/T 2 (SP, TA)Twin Oaks Family Dentistry #009447230 F St Ste D 619-427-5262 F/T 1 (FR, PE, SP, GE, TA)Village Dental Group #021040878 Eastlake Pkwy Ste 1511 619-739-4936 F/T 1 P/T 1 (SP) U

CITY OF INDUSTRYWalnut Smiles #02560521750 Valley Blvd Ste C 909-595-0807 P/T 1 U

CLAREMONTNewport Dental #012593406 Auto Center Dr 909-624-6199 F/T 7 P/T 12 (CH, SP)COLTONColton Dental Group #033235251 E Valley Blvd 909-825-0545 P/T 1 (HI, SP) U

Dental Associates of Colton #3492011080 E Washington St Ste B 909-783-9099 F/T 1 P/T 1 (SP, CH) U

St Patrick Dental Clinic #3685011200 E Washington St Ste F2 909-422-0885 P/T 2 (SP, TA) U

COMPTONLinda Onyeador, DDS #025979555 W Compton Blvd Ste 103 310-762-9292 F/T 1Sang Cho, DDS #002787402 S Long Beach Blvd 310-637-6187 F/T 1 (KO, SP, TA)CORONABright Now Dental #01178712636 Limonite Ave Ste 1A 951-808-4323 F/T 5 P/T 22 (SP, TA) U

Bright Now! Dental #010322140 W Ontario Ave Ste 105 951-735-4969 F/T 5 P/T 22 (SP) U

Canyon Dental #0238071561 E Ontario Ave Ste 103A 951-273-0555 F/T 1 (SP, HI) U

Corona Dental #029920161 N Mckinley St Ste 102 951-737-3746 F/T 1 P/T 1 (KO, SP) U

Corona Family Dental Group #0243041358 W 6th St # 101 951-734-4620 F/T 1 P/T 4 (SP, AR, FR) U

Corona Family Dentistry #0245413848 N Mckinley St Ste D 951-371-2424 F/T 1 (TA, SP)Dental Associates of Corona #0091951380 El Sobrante Rd 951-273-9580 F/T 2 (SP, TA, TH) U

Dental Health Corona #0271144264 Green River Rd 951-340-0200 F/T 3Dental R Us #0025421303 W 6th St Ste 103 951-898-2101 F/T 2Gentle Dental Corona #0329801074 W 6th St Ste 104 951-279-7650 P/T 4Hamner Square Dental #0228646987 Hamner Ave Ste 5 951-371-3464 P/T 1 (SP, VI) U

Harpreet Gill, DDS #000224360 W Foothill Pkwy 951-279-1172 F/T 1Joseph Rajabi, DDS #001604900 S Main St Ste 107 951-734-4170 P/T 1 (SP) U

Lita Hermansjah, DDS #015150916 W 6th St 951-738-1749 F/T 1 (SP, IN)Main Street Dental Group #013104131 W Ontario Ave Ste 102 951-898-9700 P/T 1 (SP) U

Mckinley Dental #011789115 N Mckinley St Ste 105 951-280-9300 F/T 1 (SP)Orchard Dental Group #0215352150 California Ave Ste 107 951-279-4333 P/T 1 (SP) U

Smile Now Dental Group #0228401760 W 6th St Ste 101 951-735-7300 F/T 1 (SP, TA, HI, CH, VI) U

Soft Care Dental #029917910 Washburn Ave Ste D 951-734-7717 P/T 1Soft Touch Dental #0106331411 Rimpau Ave Ste 106 951-280-0322 P/T 1 (SP, HI, TA)South Corona Dental Group #0042241312 E Ontario Ave Ste 102 951-273-0370 P/T 1 (SP) U

Sycamore Creek Dental #03024711882 De Palma Rd Ste E 2 951-277-7678 F/T 1CORONA DEL MARCorona Del Mar Dental Group #0292872345 E Coast Hwy Ste C 949-675-3131 P/T 1 U

COSTA MESAAdvan Dental Care #0126981503 S Coast Dr Ste 201 714-540-8547 P/T 2 (CH, SP) U

Bay Mesa Dental Office #0327702023 Harbor Blvd Ste D 949-646-9000 P/T 1 (SP, VI)Bright Dental Care #013279320 Bristol St Ste H 714-546-7595 F/T 2 (SP, PE) U

Bright Now! Dental Costa Mesa #0335812300 Harbor Blve Ste H-5 949-610-0146 P/T 9 (AR, SP)Dazzling Smile Dental Group #006360204 E 17th St Ste 201 949-515-8181 F/T 1 (AR, SP, HU) U

Fashion Dental #033267145 E 19th St Ste A 949-650-1414 F/T 1 U

Gentle Dental-Costa Mesa #0301012000 Harbor Blvd Ste B100 949-645-5070 F/T 3 P/T 3 (CH, PE, SP, TA, TR) U

Mehri Safari, DDS #0170462969 Harbor Blvd 714-424-9393 F/T 1 (SP, PE)Mesa Dental Center #196301267 E 17th St 949-646-2411 F/T 2 (AR, SP, HI, TH)Newport Dental Group #0221561835 Newport Blvd Ste E267 949-574-0100 P/T 1 (SP, PL, PE) U

Pacific Harbor Dental Group #0131683030 Harbor Blvd Ste G1 714-546-6100 P/T 1 (SP) U

So Cal Smiles Dentistry #029184230 E 17th St Ste 208 949-645-0045 P/T 1 (AR, TA, RU, SP) U

COVINAAhmed Saeed, DDS., Inc #015597661 S 2nd Ave 626-966-3571 P/T 1 (PE, SP)Arrow Smile Dental Clinic #02366820530 E Arrow Hwy 626-938-1236 F/T 1 (TA) U

College St Family Dtl Grp #032182153 W College St At 626-339-9085 P/T 1 (KO, SP)Covina Dental Office #0C59011052 N Citrus Ave 626-967-6767 F/T 1 P/T 1 (AR, PE, SP, VI) U

Dental Group of Covina #0007691406 N Azusa Ave Ste C 626-858-9940 P/T 1 (CH, SP) U

Patricia Lopez, DDS., Inc #023360675 S 2nd Ave 626-938-0195 F/T 1 (SP)Rubin Nichols, DDS., Inc #025177558 W Badillo St 626-331-0506 F/T 1 P/T 1


10 27

• Any service that is not specifically listed as a covered procedure.

• Dental expenses incurred in connection with any dental procedure started prior to the enrollee’s eligibility. Example: teeth prepared for crowns, root canals in progress, orthodontics.

• Congenital malformations.

• Dispensing of drugs not normally supplied in a dental office.

• Cases in which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained or where the prognosis is poor or guarded.

• Dental services received from any dental office other than the assigned dental office unless expressly authorized in writing by Delta Dental or as cited under “Emergency Services”.

• Prophylactic removal of impactions (asymptomatic nonpathological).

• “Consultations” for noncovered services.

• Implant placement or removal, appliances placed on, or services associated with, implants.

ORTHODONTIC LIMITATIONS AND EXCLUSIONS(PARTIAL LIST)

• Orthodontic treatment must be provided by a member of the orthodontic network.

• Program benefits cover 24 months of usual and customary orthodontic treatment.

• If your coverage is terminated for any reason, and you are receiving any orthodontic treatment at the time, your copayment shall be $2,300 for dependent children to age 19 (and $2,500 for covered adults and dependent adult children) and be prorated over the number of months to completion of the treatment. Terms and conditions are arranged between you and the orthodontist.

• A consultation fee may be charged if treatment is not required, or if you elect not to start treatment after a diagnosis and consultation have been completed.

• Pre-, mid- and post-treatment records (cephalometric x-rays, tracings, photographs and study models) are excluded.

• Retreatment of orthodontic cases is excluded.

• Lost, stolen or broken appliances are excluded.

• Orthodontic treatment in progress is limited to new DeltaCare USA enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.

When you enroll in DeltaCare USA, you select a participating dental office from the network directory to take care of dental needs for you and your family. After you have enrolled, you will receive an Evidence of Coverage booket that fully describes the benefits of your dental program, a welcome letter and a DeltaCare USA membership card. The welcome letter will have the address and telephone number of your participating network dentist. To receive all necessary dental care covered by the program, simply call your selected dental office to make an appointment.

Remember to always contact your network dentist. Dental services which are not performed by this dentist or are not authorized in advance by Delta Dental will not be covered under the DeltaCare USA program.

LIMITATIONS OF BENEFITS (PARTIAL LIST)

• Prophylaxis is limited to two treatments at no cost in any 12 consecutive months; additional treatments are available with a $27 patient copayment.

• Full upper and/or lower dentures are not to exceed one each in any five-year period.

• Replacement of partial dentures within any five-year period is not covered unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible.

• Denture relines are limited to one per denture during any 12 consecutive months.

• Periodontal treatments (root planing/subgingival curettage) are limited to five quadrants during any 12 consecutive months.

• Bitewing x-rays are limited to not more than one series of four films in any six-month period.

• Full mouth x-rays are limited to one set every 24 consecutive months.

• Sealants are limited to noncarious, nonrestored permanent first and second molars through age 15.

EXCLUSIONS (PARTIAL LIST)

The following services are not covered.

• General anesthesia and the services of a special anesthesiologist.

• Cosmetic dental care.

• Dental conditions arising out of and due to the enrollee’s employment or for which Workers’ Compensation is payable. Services which are provided to the enrollee by state government or agency thereof, or are provided without cost to the enrollee by any municipality, county or other subdivisions.

• Dental services performed in a hospital and related hospital fees.

• Loss or theft of fixed and removable prosthetics (crowns, bridges, full or partial dentures).

• Dental expenses incurred in connection with any dental procedure started after termination of eligibility of coverage.

CUDAHYCudahy True Smile Dentistry #0309648036 Atlantic Ave 323-562-4604 F/T 1 (VI) U

St James Dental Group #0251917607 Atlantic Ave 323-771-7254 F/T 2 (PE, SP)CULVER CITYAll Care Dental #0059524310 Overland Ave 310-837-8087 F/T 1 (PE)Culver City Family Dentistry #0135144909 Sepulveda Blvd 310-313-3100 F/T 1 (SP) U

Precision Dental Inc #0150625903 Sepulveda Blvd # B 310-390-3565 P/T 1 (Pe, Sp) U

Smile Dental #00027710920 Venice Blvd 310-204-6661 F/T 1 (SP, HR, TA)West View Dental #03092510814 Jefferson Blvd Ste G 310-204-0440 P/T 2 U

CYPRESSCa Dental Group of Cypress #00867411741 Valley View St Ste E 714-826-3000 P/T 1 (SP, VI) U

Cypress Dental Group #0153089922 Walker St Ste C 714-220-0354 F/T 1 (PE, TA, SP, HE) U

Cypress Plaza Dental Group #0272535460 Orange Ave 714-226-9630 P/T 2 (SP) U

Harish Hegde, DDS #0135319111 Valley View St Ste 106 714-995-1222 F/T 1 (SP) U

Katella Dental Center #3645016929 Katella Ave 714-952-3044 F/T 2 (VI)DANA POINTDana Point Dental Group #01900434080 Golden Lantern St 949-661-5664 P/T 2 (IT, PE, SP, TH) U

DEL MARDel Mar Professional Dtl Grp #00727213983 Mango Dr Ste 104 858-792-666 P/T 1 (SP, PE)DELANOLeticia Tolentino, DMD Inc #0138571625 Cecil Ave Ste A 661-725-9393 F/T 1 (SP, TA) U

DIAMOND BARDiamond Dental Care #3C4401303 S Diamond Bar Blvd # 2C 909-860-7579 P/T 2 (EI, SP, PE)Edward Mousally, DDS #36000123525 Golden Springs Dr # C 909-860-9399 F/T 1Grand Avenue Dentistry #1981011111 Grand Ave Ste G 909-396-7474 P/T 1 (SP)Wasseem Samaan, DDS #2C0601750 N Diamond Bar Blvd # 216 909-860-3111 F/T 2 P/T 1 (AR, SP) U

DOWNEYBaek Choung, DDS #0293238653 Florence Ave 562-622-0066 F/T 1 (KO, SP)Charles Stucken, DDS #3598018847 Imperial Hwy Ste C2 562-861-4011 F/T 1 (SP) U

Dental Pros #02362212156 Lakewood Blvd 562-803-1600 F/T 1 P/T 1 (SP, RU, VI) U

Downey Dental Center #2500018515 Florence Ave Ste 200 562-869-4532 F/T 1 P/T 3 (PE, SP) U

Downey Dental Group #0216858102 3Rd St 562-803-3333 F/T 2 (SP) U

Family Dental Center #03400110501 Lakewood Blvd Ste A 562-862-2341 F/T 3 P/T 1 (SP) U

Fred Bina, DDS #15260111849 Paramount Blvd 562-869-2596 F/T 3 (SP, PE)Kenneth W Cheng, DDS #0331138029 Imperial Hwy 562-862-6979 P/T 1 (CA, KO, SP) U

Planet Dental #0006468843 Rosecrans Ave Ste A 562-633-9300 F/T 2 (SP, PE) U

Quality Dentistry #0232998485 Florence Ave 562-869-2091 F/T 2 (PE, SP)Smilecare-Downey #0039559474 Firestone Blvd 562-803-4224 P/T 6 (SP) U

Soheir Azer, DDS #00275510800 Paramount Blvd Ste 307 562-923-3714 F/T 1 (AR)Ying Wu DDS., Inc #01260012651 Lakewood Blvd Ste 101 562-904-1150 F/T 1 (SP, CH)DUARTEBright Smile Family Dental #0018202233 Huntington Dr 626-359-9898 F/T 1 P/T 1 (SP) U

Duarte Family Dentistry #0841011217 Buena Vista St Ste 202 626-357-2254 P/T 1 (SP)EL CAJONAndrzej Lubczuk, DDS #029175707 Arnele Ave 619-444-1001 F/T 2 P/T 1 (SP)Cottonwood Dental Group #0134602451 Jamacha Rd Ste 104 619-444-0500 F/T 3Dr Korel Family Dentistry #3695011265 Avocado Ave Ste 102 619-444-3393 F/T 1 (AR)East County Dtl Associates #007821700 N Johnson Ave Ste P 619-444-3127 F/T 2 (AR, SP, VI)East County Family Dental Ctr #02143613465 Cam Canada Ste 110-A 619-390-3669 F/T 1 (SP, TA) U

El Cajon Family Dental #0292032720 Fletcher Pkwy 619-466-1292 F/T 1 (SP, AR)Horizon Dental Group #2C8201742 Broadway 619-440-0071 F/T 1 P/T 1 U

La Maestra Family Clinic Inc #024593183 S 1st St 619-328-1335 F/T 4 (SP, AR) U

Pacific Dental Grp- El Cajon #021723895 Jackman St 619-447-3100 U

Smilecare-El Cajon #0035081242 E Main St 619-444-6355 F/T 2 P/T 6 (SP)Smilecare-El Cajon II #0031542990 Jamacha Rd Ste 132 619-670-1700 F/T 2 P/T 5 (SP)Sun Valley Dental Care #0242481209 E Main St 619-442-0707 F/T 1 U

EL CENTROSouthwest Dental Group #0342501502 S La Brucherie Rd 760-482-5505 (SP)EL MONTEAlfonso Martinez, DDS #01285111733 Valley Blvd Ste A 626-575-7565 F/T 1 (SP)Central Dental Group #00378512072 Valley Blvd 626-527-2200 P/T 1 (CA, FR, JA, SP, TA, VI) U

David Kutner, DMD #0019013701 Santa Anita Ave 626-442-4582 P/T 1 (SP) U

Eastern Los Angeles Dental #00209612015 Garvey Ave Ste A 626-454-1888 F/T 1 (CH, SP) U

Family Dentistry #0028259060 Telstar Ave Ste 206 626-571-5975 F/T 1 (RO, HU, SP) U

Khan Dental Corporation #3596014900 Peck Rd 626-579-5158 F/T 2 (SP, HI) U

May Valley Dental Center #01926311766 Valley Blvd 626-448-5000 P/T 1 (SP) U

Mountain View Dental Group #0095574639 Peck Rd 626-444-9281 P/T 1 (SP, VI, CH)Select Dental Practice #0162303116 Peck Rd 626-454-2444 P/T 1 (SP, AM, FR, AR)

Shahriyar Behjou Dtl Corp #00171510755 Lower Azusa Rd Ste B 626-448-2040 F/T 2 P/T 1 (SP, TA, VI) U

Sunshine Dental Group #0195514161 Tyler Ave 626-579-4274 F/T 2 (CH, SP)Swe Dentistry #02041910354 Garvey Ave Ste B 626-350-8366 P/T 1 (SP) U

Tessie T Sy, DDS #0121064565 Peck Rd 626-350-3295 F/T 1 (CH, SP, TA)Victor Martin, DDS #0038243564 Santa Anita Ave Ste F 626-401-9808 F/T 1 (SP) U

ENCINITASCamino Dental Group #0146051340 Encinitas Blvd # 100 760-942-3900 P/T 2 (SP) U

ENCINOA One Dental Office #03379817175 Ventura Blvd 818-788-3488 F/T 1 (SP, TA) U

Dan Rosen, DDS #16460116542 Ventura Blvd Ste 505 818-907-6736 F/T 3 (HE, SP) U

Daniel Tebbi, DMD #03295616661 Ventura Blvd Ste 620 818-789-2034 F/T 1 U

Encino Cosmetic Dental Group #02386516133 Ventura Blvd Ste 1100 818-906-2222 F/T 1 (SP, PE) U

Encino Dental Center #18440117815 Ventura Blvd Ste 101 818-708-1200 F/T 1 (HE, SP)Encino Dental Esthetics #01996117525 Ventura Blvd Ste 100 818-784-7832 F/T 1 (SP, PE) U

Encino Family Dental Group #23750115720 Ventura Blvd Ste 322 818-788-7060 F/T 2 (FR, HE, TA) U

Encino Smile Center Inc #01824515720 Ventura Blvd Ste 300 818-788-6684 P/T 1 (AM, AR, RU, TA) U

Iraj Ebrami, DDS #00286116311 Ventura Blvd Ste 640 818-905-8337 P/T 1 (HE, PE) U

Moshe Abramovici, DDS #01761916550 Ventura Blvd Ste 403 818-986-0898 P/T 1 (HE, RO) U

Rene Ghotanian, DDS #1799015363 Balboa Blvd Ste 346 818-990-3551 F/T 1 (Sp)ESCONDIDOAcacia Dental Care #003541639 S Escondido Blvd 760-489-6197 P/T 2 (SP)El Norte Family Dental #154801306 W El Norte Pkwy Ste D E 760-480-5600 P/T 1 (SP)Escondido Dental Group #007041403 W Felicita Ave 760-233-2260 P/T 1Family Care Dental #1918011114 W Valley Pkwy 760-738-1070 F/T 1 P/T 1 (Sp, Ta, Vi)Gentle Dental-Del Lago #0051323440 Del Lago Blvd Ste C 760-746-8777 F/T 2 P/T 1Shahriyar Zandkarimi, DDS #005335240 W Mission Ave Ste A B 760-747-7000 F/T 1Village Dental Center #1969018895 Lawrence Welk Dr 760-749-7500 F/T 1FONTANABright Now! Dental #01795216135 Sierra Lakes Pkwy 909-356-2006 F/T 8 P/T 18 (KO, SP) U

Dr Voras Gateway Dtl Ofc #00766115032 Summit Ave Ste 410 909-899-3940 F/T 1Fontana Dental Group #1513019193 Sierra Ave Ste D 909-822-2226 F/T 3 (PL, SP, TA)Gupta Dental Group #32520111623 Cherry Ave Ste B2 909-355-1485 F/T 1 P/T 1 (SP, HI)Gupta’s Dental Office #03062116049 Baseline Ave Unit 3 909-356-9752 F/T 2 U

Heritage Dental Care #3C29017360 Cherry Ave Ste 340 909-355-9350 F/T 1 P/T 1 (SP, HI) U

Laura Jimenez, DDS #02831517500 Foothill Blvd Ste C2 909-357-7000 F/T 1 (SP) U

Morningside Dental Group #01601414584 Baseline Ave Ste 340 909-822-7374 F/T 1 (HI, SP, PE) U

Narendra Vyas, DDS., Inc #3686019647 Sierra Ave 909-823-5959 F/T 1 (SP, HI) U

Sahara Dental #01355417250 Foothill Blvd Ste E 909-428-8500 P/T 1 (AR, SP)Sierra Family Dentistry #0168929870 Sierra Ave Ste B 909-823-2020 P/T 1 (SP, HI, AR)Sierra Lakes Dental Group #02105616475 Sierra Lakes Pkwy 909-357-0869 P/T 2 (VI, SP) U

Sierra Pkwy Dental Care #03353216953 Sierra Lakes Pkwy #110 909-357-3900 P/T 1 (HI, SP) U

Triangle Dental Group #01411614305 Baseline Ave 909-355-1700 F/T 1 P/T 1 (SP) U

Vahan Grigoryan, DDS #0156127993 Sierra Ave Ste H 909-428-5111 F/T 1 (SP, KO) U

Viven Maghiran, DDS #02836914755 Foothill Blvd Ste E 909-349-1360 F/T 1 U

FOOTHILL RANCHTowne Centre Dental Group #01942145 Auto Center Dr Ste 110 949-588-5906 P/T 2 (HI, PE, SP, TA) U

FOUNTAIN VALLEYDavid Cohen, DDS #00251611180 Warner Ave Ste 451 714-444-4428 F/T 1 (SP) U

Fountain Valley Dental Esth #01683617900 Brookhurst St Ste A 714-887-4337 F/T 1 P/T 1 (KO, SP) U

Quality Dental Care #38420117150 Euclid St Ste 311 714-444-4224 F/T 1 (AR, RU, SP) U

Wadid Fattouch, DDS 186301 11180 Warner Ave Ste 251 714-557-8492 F/T 1 (AR, FR, PE, SP, VI) U

FULLERTONA Dentistry #014793536 W Commonwealth Ave Ste A 714-449-1686 P/T 1 (SP) U

Alice Skuben, DDS #364101170 N Raymond Ave 714-870-2000 F/T 2 (CS, SP) U

Amit Shah, DDS #010880137 W Chapman Ave Ste A 714-738-6001 F/T 1Brite Dental Group #0131741573 S Harbor Blvd 714-224-5255 P/T 1 (PE, SP) U

Eric Meyer, DDS #2760012720 N Harbor Blvd Ste 110 714-879-7943 P/T 1Fullerton Dental Center #010101446 E Commonwealth Ave 714-680-6767 F/T 1 P/T 1 (KO, SP) U

Fullerton Family Dental #033363906 W Orangethorpe Ave 714-871-3900 F/T 1 (CH, SP, TA)James Chou, DDS #0333642949 Brea Blvd 714-710-0300 F/T 1 P/T 1 (SP, VI)Jane Skuben, DDS #0137881690 N Placentia Ave 714-528-0600 P/T 1 (SP, CH, TA) U

Newport Dental #0039891718 W Orangethorpe Ave 714-525-3855 F/T 5 P/T 11 (SP)Nilar Thein, DDS #017507717 N Placentia Ave 714-577-0105 P/T 2 (SP)Real Dentistry #026775100 Laguna Rd Ste 202 714-525-2888 F/T 1 (SP, TA, VI)Sayed Fazey, DDS #0328801105 S Euclid St Ste E 714-738-0304 F/T 1 U

Sunshine Dental #015258506 W Commonwealth Ave 714-738-7777 F/T 1 (SP)Us Dental #0047161019 N Harbor Blvd 714-992-0300 F/T 1 (PE, SP) U

Valencia Family Dental Care #015610345 S Euclid St Ste A 714-773-9300 F/T 1 P/T 1 (HI, SP) U

GARDEN GROVEBrentwood Dental #02286012400 Euclid St 714-537-1600 F/T 1 (VI) U

Brookhurst Dental Group #03112612132 Brookhurst St 714-638-7111 P/T 1 (SP, HI) U

Century Dental Care #01170113011 Century Blvd 714-534-7020 F/T 1 (KO, SP) U

Coastal Dental Care #00788010044 Westminster Ave 714-539-7070 F/T 3 P/T 1 (KO, SP)Garden Grove Dental #00883312630 Brookhurst St Ste B 714-530-4920 F/T 3 P/T 1 (FR, SP, TA, HU, CS, RU, VI) U

Leaders Dental Group #02152813031 Kerry St 714-530-9901 P/T 1Mass Dental #0327729520 Garden Grove Blvd # 14 714-537-9160 P/T 1Primary Dental Care #00029712570 Brookhurst St Ste 2 714-537-5700 F/T 1 (RU, SP) U

Universal Care Dental #12740112511 Brookhurst St 714-530-9801 F/T 3 (SP, VI) U

GARDENAAll Friends Dental Center 028370 1600 W Redon Bh Blvd Ste 203 310-808-0198 F/T 1 P/T 1 (CA, SP)City Dental Center #0018131300 W 155th St Ste 208 310-715-2723 P/T 1 U

Dr Ly Vina Dental Group #02932815422 Crenshaw Blvd 310-352-4939 P/T 1 (VI) U

Harry Kim, DDS #01923415400 Crenshaw Blvd 310-516-9858 F/T 1 (SP, KO)Plaza Dental #17330114240 S Vermont Ave 310-515-5511 F/T 2 (SP) U

GLENDALEAlenoush Bagdasaryan, DDS #001666457 Palm Dr Ste 100 818-956-3733 F/T 2 (AM, SP, PE, RU)Artemis Saradjian, DDS #003132205 S Verdugo Rd Ste A 818-244-4949 F/T 3 (AM, PE, RU, SP)Broadway Dental Office #162301727 E Broadway 818-240-5888 F/T 1 (Sp) U

Carmen Ohanian, DDS #012933607 N Central Ave Ste 301 818-244-0215 F/T 1 (AM, PE, RU) U

Central Dental Care #0018171110 N Brand Blvd Ste 202 818-242-4781 P/T 1 (AM, PE, SP)Cyberdent #0110816300 San Fernando Rd 818-547-4455 F/T 1 (AM, RU)Daniel Estacio, DDS #0137391140 E Chevy Chase Dr 818-247-3387 F/T 1 P/T 1 (SP, TA) U

Dental Care Studios #0299151141 N Brand Blvd Ste 500 818-240-3700 F/T 1 (AM, PE, RU, FR) U

Dental Central Group #027579814 E Broadway Ste 4 818-241-1160 P/T 1 (SP, AM) U

Fmly Dtl Health Dr Ligaya #028264125 E Glenoaks Blvd Ste 107 818-484-8508 F/T 1Glendale Premier Dtl Center #023481819 N Pacific Ave 818-240-1760 F/T 1 P/T 1 (SP, AM, GE, FR)Hamlet Davari, DDS #1883011110 N Brand Blvd Ste 202 818-782-8120 P/T 1 (AM, PE, SP)


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n WHO CAN JOIN

As a Federal member of Kaiser Permanente, you are eligible to join the DeltaCare USA program.

Your eligible dependents include your lawful spouse and unmarried children under 26 years old, including stepchildren and children placed with you for adoption or foster care. An unmarried child 26 years of age or older may continue to be eligible as a dependent if incapable of self-support because of physical handicap or mental retardation that commenced prior to age 26, provided that the person is legally residing with and dependent upon the eligible member, and Delta Dental receives notice of the disability.

n EMERGENCY SERVICES Dental emergencies are covered up to a maximum of $100.00 per

emergency.

n NO CLAIM FORMS The dental location you choose provides all primary dental

services. There are no claim forms to complete or percentage of usual charges for you to pay.

n NO DEDUCTIBLES With the DeltaCare USA program, there are no required

deductibles to pay, so your benefits begin immediately.

n NO DOLLAR LIMIT OF DENTAL BENEFITS No annual maximum.

n PRE-EXISTING CONDITION RESTRICTIONS Pre-existing conditions are not excluded in the DeltaCare USA

program. Exception: work in progress.

n PREPAID PROGRAM SAVES ON DENTAL COSTS Your out-of-pocket savings could be substantial. You know the

exact cost prior to treatment, allowing you to predict future dental expenses.

When you enroll in this program, you are enrolling for a period of one year. This does not apply if your employment is terminated.

n QUALITY REVIEW OF DENTAL PROVIDERS On-site audits of participating dental locations ensure that

established standards of quality are maintained.

n SPECIALTY SERVICES The DeltaCare USA program offers services in dental specialty

areas. These include periodontics (treatment of diseased gums and bone), endodontics (root canal therapy) and oral surgery procedures. Sepcialty services must be referred by the assigned network dentist and preauthorized, in writing by Delta Dental. If an enrollee is assigned to a dental school clinic for specialist services, those services may be provided by a dentist, a dental instructor, a clinician or a dental student under the supervision of a dentist.

The DeltaCare USA program provides all reasonable and customary dental care (subject to the provisions, limitations and exclusions shown in the Combined Evidence of Coverage and Disclosure Form) if care is provided by your assigned network dentist.

One of your non-FEHB Dental benefit options, DeltaCare USA, is administered by Delta Dental of California.

With DeltaCare USA, you select a conveniently located network dentist to provide dental care for you and your family. You pay a small copayment or, for some services, no copayment. There are no deductibles and no claim forms to worry about.

The dues for 2011 are listed below:

NOTE: This is only a brief summary of the program. An Evidence of Coverage stating the terms of your program will be sent to you upon enrollment.

These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are made available to all enrollees and family members of this Plan.

Dues* Monthly* Quarterly*

Self Only $ 11.89 $ 35.67 Self & One Party $ 19.90 $ 59.70 Self & Two or More $ 30.17 $ 90.51 *Good through December 31, 2011.

Please read the following information so you will know how to get dental care under the

DeltaCare USA program.

n About DeltaCare USA

The DeltaCare USA program is an HMO dental plan that focuses on preventing dental problems and assuring the delivery of quality dental care.

Delta Dental has contracted with a network of dental offices. A listing of these offices is included for you in the back of this brochure, or you may go to www.deltadentalins.com to search for a conveniently located network dentist. The network of dental offices is composed of established dental practices.

DeltaCare® USAJerry Kolesar, DMD #3657011122 N Brand Blvd Ste 102 818-242-2667 F/T 2 (SP)\John Gazarian, DDS #171801230 N Maryland Ave Ste 205 818-502-9990 P/T 1 (AM, PE, SP, TA, RU) U

John Yekikian, DDS #2359011128 N Brand Blvd Ste A 818-242-4703 F/T 1 (SP, AM)Khodaverdian Njdeh, DDS #030036428 Arden Ave Ste 100 818-547-4020 F/T 2 (AM, PE) U

Melineh Arakelian, DDS #013063411 N Central Ave Ste 120 818-956-7137 F/T 1 (AM, PE, SP) U

Montrose Dental Group #3C46013600 Ocean View Blvd Ste 6 818-541-9010 F/T 2 (AM, PE, RO)New Smile Dental Group #012588204 E Chevy Chase Dr Ste 1 818-547-4398 P/T 1 (AM, RO, AR, FR, GE, PE)Ovsep Lusinyan, DDS #028263501 W Glenoaks Blvd Ste 14 818-500-7979 F/T 1Prodent Care Dental Practice #030727213 N Orange St Ste F 818-241-3155 F/T 1 (SP, AM, PE) U

Smile Dental Practice #0023751114 E Broadway 818-500-7740 F/T 1 (AM, PE, RU) U

Starlight Dental Group #028405214 N Central Ave 818-243-8888 F/T 1 (AM, SP, PE, RU)Teeth & Gums Central Dntistry #018577730 S Central Ave Ste 116 818-545-3515 P/T 1 (TA) U

Town Center Dentistry #013449316 E Broadway Ste A 818-548-7700 F/T 1 (AM, SP, TA) U

Zareh Baghoomian, DDS #0110961010 N Glendale Ave Ste 206 818-548-0752 F/T 1 (AM, PE) U

GLENDORAFriendly Dental Care #030531335 W Arrow Hwy 626-914-6663 F/T 1 (AR, SP, PE, TA) U

Glendora Dental Center #288401130 W Route 66 Ste 316 626-335-7727 F/T 1 (TA, SP, PE)Glendora Smiles Dental #021055605 W Route 66 626-771-1320 F/T 1 P/T 1 (SP, PE, GE, FR) U

Harry Pages, DDS #191001641 W Route 66 Ste D 626-914-3068 F/T 1 (SP) U

Lone Hill Dental #0192721331 S Lone Hill Ave Ste 185 909-305-1015 P/T 1 (SP, VI) U

Shawky Soliman, DDS., Inc #013849150 S Grand Ave Ste F 626-914-3150 F/T 1 (AR, SP) U

Smile Bright #0325951814 E Route 66 Ste B 626-963-7000 F/T 1 (SP) U

Woodglen Dental Center #016959220 S Glendora Ave Ste B 626-914-4054 P/T 1 (AR, SP)GOLETAGoleta Dental Practice #018804164 Kinman Ave Ste B 805-683-7777 F/T 1 (SP, HI)GRANADA HILLSBalboa Dental Group #02051911850 1/2 Balboa Blvd 818-360-1946 P/T 1 (PE, SP) U

Buenaventura Dental Inc #03195016917 Devonshire St 818-360-0957 P/T 2 (TA) U

Buenaventura Dental Inc #03195118121 Chatsworth St 818-360-1500 P/T 1 (TA) U

John Bosak, DMD #320001 10727 White Oak Ave Ste 213 818-368-5676 F/T 2 (PE, SP)Kamran Rafie, DDS #17170110144 Balboa Blvd 818-363-0200 F/T 2 (SP, PE) U

GRAND TERRACEMarileth Coria, DDS #00234122575 Barton Rd 909-825-6003 F/T 1 (SP)

HACIENDA HEIGHTSComfort Smile Fmly Dentistry #2C940115724 Gale Ave 626-333-5244 F/T 1 (CH, SP)Katy Chou Family Dentistry #03083817138 Colima Rd Ste C 626-854-1826 P/T 1 (CH, SP) U

Tri City Smiles Dtl Grp #02380517188 Colima Rd Ste B 626-581-7878 F/T 1 P/T 1 (HI, SP) U

Viola Iskarous, DDS #0126842440 S Hacienda Blvd Ste 233 626-968-0052 F/T 1 (SP)HARBOR CITYBay Harbor Dental Office #2C91011537 Lomita Blvd 310-530-5252 F/T 2 (SP) U

HAWAIIAN GARDENSGentle Dental Care #02385512144 Carson St Ste E 562-982-1380 P/T 1 (SP, KO) U

Keun Chan Lee, DDS #01207312531 Carson St 562-924-2448 F/T 1 (KO, SP) U

Newport Dtl-Hawaiian Gardens #01343421714 Pioneer Blvd 562-421-3737 F/T 2 P/T 6 (HI, SP) U

HAWTHORNEAll Kids Dental Care #03024813340 Hawthorne Blvd 310-973-8004 F/T 1Behdad Omrani, DDS., Inc #02506913637 Hawthorne Blvd Ste 101 310-644-2310 F/T 1 (PE, SP)Castle Dental Centers #01564913220 Hawthorne Blvd 310-679-9019 F/T 2 P/T 10 (SP) U

Choice Dental Group #3C490112730 Hawthorne Blvd Ste D 310-644-4000 P/T 2 (SP, PE, KO) U

Comfort Dental Center #1659014277 W El Segundo Blvd 310-970-0900 F/T 2 (SP, PE) U

Daily Dental Group #02506611633 Hawthorne Blvd Ste 502 310-644-4464 F/T 1 P/T 1 (SP, JA)Dr Gary Gee DDS #01941314115 Crenshaw Blvd Ste 1 310-644-0474 F/T 1 (CA, SP)Hawthorne Dental #01120113935 Hawthorne Blvd 310-973-6428 P/T 1 (SP)Hawthorne Dental Care #0189774477 W 118th St Ste 500 310-970-9255 F/T 1 (SP) U

Hawthorne Fmly & Cosmetic Dtl #00752913402 Hawthorne Blvd 310-675-5050 F/T 1 (SP)John Legaspi, DMD #0C450113352 Hawthorne Blvd 310-973-1525 P/T 1 (SP)Sunrise Dental Group #01294613624 Hawthorne Blvd Ste 205 310-856-6574 F/T 1 (SP)HEMETBright Now! Dental #0168012721 W Florida Ave 951-925-2226 F/T 3 P/T 13 (SP)Gregory Skinner Dental Corp #032178250 S Lyon Ave Ste B 951-658-2354 F/T 1 (SP) U

Hemet Dental Care #0198981300 E Florida Ave 951-765-5544 P/T 1 (SP) U

Hemet Dental Clinic #004077940 E Morton Pl 951-652-2796 F/T 1Hemet Dental Group #0121504000 W Florida Ave 951-658-9980 P/T 2 (SP, AR, FR, HI) U

Hemet Smiles #0220691001 S State St Ste B 951-658-6100 P/T 1 (SP) U

HESPERIABright Now Dental #01851717003 Bear Valley Rd Ste D 760-244-1900 F/T 2 P/T 5 (SP) U

Dental Group of Hesperia #00923815776 Main St Ste 18 760-949-8484 P/T 1 (PE, SP)Desert Valley Dental Grp #39100117247 Main St 760-244-2625 P/T 1 (RU, SP, TA, VI) U

Family Dentistry #02142315550 Main St Ste B7 760-947-7777 F/T 1 (PE, SP, TA) U

Gentle Dental #01368816455 Main St Ste 17 760-244-6077 F/T 4 P/T 3 U

High Desert Smiles Dentistry #02691712821 Main St Ste 150 760-947-9853 P/T 2 (SP)HIGHLANDHighland Dental Group #02740527949 Greenspot Rd Ste H 909-864-6010 P/T 1Inland Dental Ctr Highland #0161356982 Boulder Ave 909-862-2121 F/T 1 P/T 1 (SP) U

HOLLYWOODArnold Rifman, DDS #3890016234 Fountain Ave 323-466-2937 F/T 1 (RU, SP) U

Said Aly, DDS #0159011680 Vine St Ste 1020 323-464-2033 F/T 1 (AM, AR)HUNTINGTON BEACHBeach Dental Group #00309319720 Beach Blvd # B 714-593-1010 F/T 1 P/T 3 (SP) U

Beach Dental Group #0117189842 Adams Ave Ste 106 714-968-4907 F/T 1 P/T 2 (SP) U

Beachside Dental Group #20070118800 Main St Ste 110 714-842-6151 F/T 1 P/T 5 (SP, VI, IT, TA, AR) U

Bella Terra Dentistry #02326516261 Beach Blvd 714-847-2220 F/T 1 (SP, VI) U

Big Dental Group #03094118682 Beach Blvd Ste 100 714-968-3522 F/T 1 P/T 1 (SP, PE, TR) U

Coastline Dental Care #01923616033 Bolsa Chica St Ste 110 714-846-7700 P/T 1 (SP, VI) U

Cosmetic & Dental Implant Ctr #02963419080 Brookhurst St 714-968-2527 P/T 1 (SP, VI) U

Dtl Assoc of Huntington Beach #0113895942 Edinger Ave Ste 101 714-377-4449 P/T 2 (PE, SP, KO, AR) U

Family Dental Care #0295829952 Hamilton Ave 714-593-0256 P/T 1 (SP) U

Harbour Landing Dental #0155814911 Warner Ave Ste 202 714-846-4414 P/T 1 (SP) U

Kathleen Collins, DDS #01722016052 Beach Blvd Ste 120 714-887-0444 F/T 1 (SP) U

Kosmas Pappas, DDS #00741910106 Adams Ave 714-962-7797 P/T 1 (SP) U

Lina Musleh, DDS #00018519754 Beach Blvd 714-964-8830 F/T 1 (SP)Pacifica Dental Group #01730218821 Delaware St Ste 101 714-848-8211 P/T 3 (AR, TA, PE, SP, VI)Pearly White Dental #01189116474 Bolsa Chica St 714-377-3736 F/T 1 (SP, VI) U

Smart Dental #02569016152 Beach Blvd Ste 140 714-847-5100 P/T 1 (AR, SP, TA, KO, CH, VI)Subodh Swaroop, DDS #02413010028 Adams Ave 714-962-4070 F/T 1 (SP)Yorktown Dental Practice #0032099931 Yorktown Ave 714-963-9809 F/T 1 (SP)HUNTINGTON PARKAndrew Shieh DDS and Assocs #0125802563 Zoe Ave 323-588-6384 F/T 1 P/T 1 (CH, SP) U

Belenda V. Abanilla Dental #0130503017 E Florence Ave 323-584-1171 F/T 1 (SP, TA)Binafard Dentaland #0129197136 Pacific Blvd Ste 210 323-585-1000 P/T 1 (FR, PE, SP)Dr Fransis Dental Center #0287126040 Pacific Blvd 323-583-5677 F/T 3 (AR, PE, SP)

Huntington Family Dental #3924012542 E Florence Ave Ste A 323-582-0755 F/T 1 P/T 1 (PE, SP) U

Huntington Park Family Dental #0023762711 E Slauson Ave 323-582-4474 F/T 1 P/T 1 (AR, SP) U

Justin Family Dentist #3761017208 Pacific Blvd Ste 200 323-582-2200 F/T 1 (KO, SP) U

Kids And Adult Dental Care #0126252625 E Florence Ave Ste C 323-277-9191 F/T 1 (PE, SP)Kims Family Dentistry #2702017601 Seville Ave 323-587-6600 F/T 1 (KO, SP) U

Pacific Family Dentistry #0024885914 Pacific Blvd 323-581-0100 F/T 1 (KO, SP) U

Seville Dental Center DDS #3558017705 Seville Ave Ste A 323-582-6938 F/T 1 (SP) U

Your Choice Dental #1582016601 Rugby Ave Ste 400 323-585-1515 P/T 2 (RU, SP) U

Your Chois Dental #0040693131 E Florence Ave 323-585-3332 F/T 1 (KO, SP) U

Huntington ParkPro Dentista #0326412634 Clarendon Ave 323-585-2777 F/T 1IMPERIALPeoples Dental Office #1853012387 US Highway 86 760-353-5100 F/T 2 (SP)IMPERIAL BEACHImperial Beach Dental Group #0245421340 Imprl Bch Blvd Ste 202 619-429-6600 F/T 3 (SP)Luis Contreras, DDS #0165811340 Imprl Bch Blvd Ste 101 619-575-6644 F/T 1 (SP)INDIOGentle Dental Indio #01729381557 Dr Carreon Blvd Ste D3 760-775-5284 F/T 1 P/T 2 (PE, SP, TA)Granada Dental #01750881730 US Highway 111 Ste 8 760-347-7505 F/T 1 (PE, SP)Inland Dental Center #02120244100 Jefferson St # 404 760-772-0214 P/T 1 (SP) U

Lm Rojas Dental Corp #02036344200 Monroe St 760-775-3938 F/T 1 (SP) U

Town & Country Dental #023264 81637 Highway 111 SW #1760-342-1448 P/T 1 (RU, SP, AM) U

INGLEWOODAesthetica Dental Inc #0216773451 W Century Blvd Ste B1 310-330-9000 F/T 2 (Pe, Sp) U

Century Dental/Dr Campbell #008571257 S Market St 310-677-4767 F/T 1 P/T 3 (KO, PE, SP)Comprehensive Dental #030826141 N Prairie Ave 310-330-0080 F/T 1Crown Dental Group #0038221295 S La Brea Ave Ste 101 310-672-0129 P/T 1 (KO, SP) U

Debbie R Ballenger, DDS #033841139 N Prairie Ave 310-412-2994 P/T 1 (SP) U

Emmanuel Okonkwo, DDS #0292022710 W Manchester Blvd Ste 3 323-971-5026 F/T 1Forum Dental Group #228401400 E Regent St 310-674-7590 F/T 1 (SP) U

Imperial Crenshaw Dental Ctr #0027842798 W Imperial Hwy 323-418-8888 F/T 1 (SP, TA) U

Kaufman & Weiner DDS., Inc #0999013516 W Imperial Hwy 310-677-9101 F/T 3 P/T 1 (SP) U

Portia Turner, DDS #005593139 N Prairie Ave 310-412-2994 P/T 1Raymont Johnson Jr, DDS #375501808 E Manchester Blvd 310-671-1234 F/T 1 (SP) U

Westchester Dental Care #030246212 N Market St 310-671-9920 F/T 1 P/T 1 (PE, SP) U

IRVINECalifornia Smile Design #0024102646 Dupont Dr Ste C200 949-955-3366 F/T 1 (AR, IT, RU) U

Dental 2000 #01235533 Creek Rd Ste 210 Bldg B 949-857-6757 P/T 1 (SP, PE, HI) U

Dental Care of Irvine #0130864330 Barranca Pkwy Ste 230 949-786-1234 F/T 1 (HI, KO, SP, PE)Elite Dental Group #0292952500 Alton Pkwy Ste 203 949-861-2500 P/T 1 U

Family Dentistry on The Lake #0258144605 Barranca Prkwy #200 949-551-4336 F/T 1 (SP)Farzad Shaygan, DDS #3399014040 Barranca Pkwy Ste 140 949-559-7300 F/T 1 (PE) U

Gentle Dental #0179144950 Barranca Pkwy Ste 105 949-551-4242 P/T 2 (SP, VI) U

Malek Mansour, DDS #00059616100 Sand Canyon Ave # 330 949-585-1515 F/T 3 (AR, FR, SP) U

Michael Alijani, DDS #02927917655 Harvard Ave Ste F 949-833-8884 F/T 2 P/T 1 (SP) U

OC Dental Group #01989214130 Culver Dr Ste C 949-653-8888 P/T 1 (PE, FR, SP) U

Parkview Dental Group #01491862 Corporate Park Ste 225 949-622-0001 F/T 1 (PE, KO, SP) U

Roya Toomarian, DDS #00246133 Creek Rd Ste 130 949-786-0640 F/T 1 U

United Family Dental #0038145321 University Dr Ste A 949-653-2244 P/T 1 (AR, CH, SP)Walnut Dental Group #01462714427 Culver Dr 949-733-0486 P/T 1 (SP) U

LA CRESCENTACrescenta Family Dental #0070392644 Foothill Blvd 818-248-9988 F/T 1 P/T 1 (Am, Fr, Pe)Family Dentistry #0158413157 Foothill Blvd Ste A 818-541-9724 P/T 1 (AM, SP) U

Nina Sonin, DDS #0188813043 Foothill Blvd Ste 5 818-542-3039 P/T 1 (RU, SP)LA HABRAAkshar Dental #0251751281 E La Habra Blvd Ste 4 562-697-3788 F/T 1 (SP, HI, CH, TH)Chester Jeng DDS., Inc #002721744 W La Habra Blvd 562-691-0738 P/T 1 (SP, CH)Coastal Dental Care #0078811216 S Idaho St Ste C 714-447-8200 F/T 1 P/T 2 (SP, KO) U

Dental One #0228041875 W La Habra Blvd 562-266-0033 F/T 1 (SP, KO) U

Gentle Dental #005462331 N Harbor Blvd 562-694-3511 F/T 3 P/T 1 (SP) U

Harbor Dental Care #0095421150 E Imperial Hwy 714-992-2200 P/T 1 (JA, KO, SP) U

Kyung Yu, DDS #0312391370 S Beach Blvd Ste E 562-694-5850 F/T 1La Habra Smiles Dental #0291191250 W Whittier Blvd 562-266-9277 P/T 1 (SP, PE) U

LA JOLLAGrey Cunningham DDS-Prof Corp #0188147300 Girard Ave Ste 206 858-454-4114 F/T 1 P/T 1 U

Harmony Dental Group #0308284130 La Jolla Vlg Dr Ste 203 858-550-8000 P/T 1 (PE, SP) U

La Jolla Cosmetic/Fam #013483470 Nautilus St Ste 212 858-459-5591 P/T 1 (GE, RU, VI)


Banking information: Checking account Savings account Credit union account

Routing Transit Number (RTN):

Account number:

Branch name________________________________________________________ Branch number ______________________________________

Telephone number ( ) —

Automatic Payment Authorization — Please enclose a voided check or preprinted deposit slip from the account checked.

I (we-hereby authorize Delta/Wolfpack Insurance Services, Inc. to charge the applicable monthly dues for 12 months of dental coverage to my account designated above. I understand that coverage will become and remain effective only if there are sufficient funds at the time of the deduction. I agree to comply with the terms as outlined in the combined evidence of coverage and disclosure form. This authority is to remain in full force and effect until I notify Delta Dental in writing 30 days prior to termination. (My bank is authorized to make corrections if any should be necessary.)

Signature of enrollee ____________________________________________________________________ Date ________________________________________

Signature of spouse _____________________________________________________________________ Date ________________________________________

The first two numbers of the RTN must be 01 through 12 or 21 through 32.

(Verify this number with your bank)

29

James Smith 221122 Main St. 15-0000/0000Anyplace, NY 10000 ______________________ 20 _______

PAY TO THEORDER OF Wolfpack Insurance Services, Inc. $ DOLLARS

ANYPLACE BANKAnyplace, NY 10000For

1: 250000005 1 :2000000 86

(Please enclose a voided check or preprinted deposit slip from the account checked.)CHECKS OR MONEY ORDERS MUST BE PAYABLE TO WOLFPACK INSURANCE SERVICES, INC.

Attach check here

RTNNOTE: Staple the check in this space. Use only a check from the account that corresponds to the banking information above.Payment instructions: Payments are due retroactively to the month you and/or dependents enrolled in the Kaiser Federal Employee Dental Plan plus one month in advance. After payment and application are received, the first automatic payment will occur on the 10th of the following month and each month thereafter.

8

AUTOMATIC PAYMENT AUTHORIZATION La Jolla Dental Arts #0132827540 Fay Ave 858-729-9808 F/T 1La Jolla Dental Group #0052958950 Villa Lj Dr Ste B120 858-455-9614 P/T 1La Jolla Village Dental #0239568950 Villa Lj Dr Ste B207 858-558-3490 F/T 1Renaissance Dental Center #0167234150 Rgnts Park Row Ste 130 858-453-2070 F/T 1 P/T 2 (SP)LA MESAGentle Dental-Grossmont #2667015565 Grsmnt Ctr Dr Ste 459 619-464-3383 F/T 5 P/T 4Great Smiles of La Mesa #0244275208 Jackson Dr Ste 108 619-466-4448 P/T 2 U

La Mesa Family Dental #3C14015680 Lake Murray Blvd Ste B 619-465-3393 F/T 1La Mesa Family Dental Center #0057348881 Fletcher Pkwy Ste 325 619-697-2800 F/T 1 P/T 2 (SP)Lake Murray Dental Group #0161585308 Lake Murray Blvd Ste C 619-464-4411 P/T 1 (SP) U

Smilecare-La Mesa #0031675601 Grsmnt Ctr Dr Ste 120 619-462-2272 F/T 1 P/T 5 (SP)LA MIRADABest Care Dental #01385515651 Imperial Hwy Ste 206 562-947-2559 F/T 1 P/T 1 (SP, KO) U

Bright Dental #01792512675 La Mirada Blvd Ste 315 562-944-4745 F/T 1 P/T 1 (SP) U

Eynald Duarte, DDS #02560713960 Valley View Ave 562-944-8244 F/T 1Imperial Dental #00249315769 Imperial Hwy 562-902-9898 F/T 2 (SP, AR) U

John Westermeyer, DDS #05850111900 La Mirada Blvd Ste 7 562-947-3761 F/T 1 (SP)La Mirada Family Dental #17530113922 Imperial Hwy 562-926-7025 F/T 1 P/T 1 (SP)La Mirada Family Dentistry #02715215071 Imperial Hwy 562-947-7000 P/T 2 (AM, SP) U

Magdy & Alina Gad #35940112252 La Mirada Blvd 562-943-0151 P/T 2 (SP) U

New Age Dental #01276014545 Telegraph Rd 562-777-1188 F/T 1 (SP, PE) U

LA PALMALicauco-Tan Dental Corp #34750130 Centerpointe Dr Ste 10 714-994-0888 F/T 2 (SP, TA) U

LA PUENTEAmerican Dental Care #0312051206 N Hacienda Blvd 626-917-8630 F/T 1 (CH, SP) U

Fairgrove Family Dentistry #03143615260 Fairgrove Ave 626-968-4733 P/T 1 (CH, SP, Vi)La Puente Village Dentistry #002085401 S Azusa Ave Ste A 626-810-8222 P/T 1 (SP)Vijay Pharar, DDS #00382317311 Valley Blvd # D 626-810-2444 F/T 1 (SP) U

LA QUINTABright Now! Dental #01923079255 Highway 111 Ste 1 760-771-1200 F/T 2 P/T 7 (SP) U

La Quinta Dental Group #00063178595 Highway 111 Ste 300 760-771-0300 F/T 2 (CH, SP)LA VERNEDental Care of La Verne #1727012323 Foothill Blvd 909-596-1861 P/T 1 (CH, SP) U

Enayda Enabe, DMD #0239092025 Foothill Blvd # B 909-593-1347 F/T 1 (SP, TA)

Laverne Dental Group #0064232216 Foothill Blvd 909-392-3899 F/T 1 P/T 2 (SP) U

LAGUNA BEACHJoseph Levingston, DDS., Inc #024253385 N Coast Hwy 949-494-7115 P/T 1 (SP)Laguna Beach Dental Group #00150331796 Coast Hwy 949-415-1020 P/T 1 (SP) U

LAGUNA HILLSAida Shahangian, DDS #02995623961Cle De La Magdalena 431 949-588-7525 F/T 1Akash Lapsi, DDS #02891323521 Paseo De Valencia 300 949-770-7766 F/T 1 U

Brilliant Smile #01494123024 Lake Forest Dr Ste A 949-716-7166 F/T 1 (GE, PE, SP) U

Duc Vu, DDS #00189023595 Moulton Pkwy Ste I 949-454-0499 P/T 1 (SP, VI) U

Farshad Saghatchi, DDS #01706526534 Moulton Pkwy Ste D 949-831-8100 P/T 1 (PE, PL, SP) U

Flora Simtchera, DDS #03112724022 Calle De La Plata #450 949-830-0074 P/T 3 (CH, PE, SP, TA)Oakbrook Dental Center #00952824351 Avenida De La Carlota 949-951-7800 F/T 1OC Dental Group #03061525401 Alicia Pkwy Ste J 949-587-3010 P/T 1 (PE, SP) U

Ruxanda Ghibu, DDS #3C010124401 Ridge Route Dr # A107 949-588-2112 F/T 1 (SP)S C Dental Care #00494122972 Moulton Pkwy Ste 106 949-770-3010 P/T 1 (FR, SP) U

LAGUNA NIGUELChoice Dental Care #01479230262 Crown Valley Pkwy # E 949-363-0018 F/T 1 (AR, FR, PE, SP, TR)Dental 2000 #03053230012 Crown Valley Pkwy # B 949-495-2866 P/T 1 (HI, PE, SP) U

Laguna Niguel Dental Group #00192527901 La Paz Rd Ste D 949-389-9195 P/T 2 (SP, VI) U

Rancho Niguel Dental Group #170601 30140 Town Center Dr 949-249-4180 F/T 3 P/T 1 (SP, VI)Sea Country Dental #1C270132341 Golden Lantern Ste B 949-496-7910 F/T 2 P/T 1 (GE, VI)Sobhi Batniji, DDS #30480130231 Golden Lantern Ste D 949-363-1200 P/T 1 (Ar, Fr)LAGUNA WOODSChristine Chung, DDS #1C810124310 Moulton Pkwy Ste C1 949-859-3988 F/T 4 (PE, SP, VI)Leisure Dental #01493424102 El Toro Rd Ste A 949-830-6510 F/T 1 P/T 1 (AR, CH, HI, VI) U

LAKE ELSINORECanyon Lake Dental #02289725321 Railroad Canyon Rd 951-244-2311 F/T 1 (SP) U

Elsinore Hills Fmly Dentistry #00254731500 Grape St Ste 8 951-471-1628 P/T 1 (SP) U

Lake Elsinore Dental Group #18740132235 Mission Trl Ste 8 951-674-6808 F/T 1 (SP)Marketplace Dental Group #01532729273 Central Ave Ste A 951-245-8664 F/T 1 P/T 1 (SP) U

Oak Grove Dental Group #01777818285 Collier Ave Ste B 951-471-0034 P/T 2 (SP) U

Tuscany Dental #161201361 Railroad Canyon Rd Ste A 951-471-1400 P/T 1 (AR, SP, RO) U

LAKE FORESTDimension Dentistry #00059520671 Lake Forest Dr # B103 949-458-2582 F/T 1 (GE, SP, VI) U

Heritage Dental Group #01752522373 El Toro Rd 949-951-5503 P/T 2 (CH, JA, SP) U

Lake Forest Dental Group #0C480123704 El Toro Rd Ste A 949-770-9355 P/T 1 (SP) U

Lake Forest Dentistry #03104120025 Lake Forest Dr Ste 105 949-595-4322 F/T 2 (PE, VI) U

Marina Dental #01327823591 El Toro Rd Ste 130 949-597-8808 F/T 1 U

Morgan Dental #02891623572 El Toro Rd Ste E 949-206-9000 P/T 1 U

Smilecare Dental Group #01334723622 Rockfield Blvd 949-837-2766 F/T 1 P/T 4 (SP) U

LAKEWOODD and D Dental Office #0132234180 Woodruff Ave 562-938-9514 F/T 1 P/T 1 (VI, SP) U

David Goren & Assoc #2106015203 Lakewood Blvd 562-531-7373 F/T 2 (SP) U

Jiten Vasa, DDS #32920111455 Carson St Ste E 562-860-7116 F/T 1 (SP, HI)Lakewood Cerritos Dtl Ctrs #0336705819 Adenmoor Ave 562-804-2296 F/T 1 (SP, TA) U

Lakewood Dental Arts #0529015555 Del Amo Blvd 562-866-1735 F/T 3 (SP)Lakewood Plaza Dental Group #0158364346 South St 562-408-3500 P/T 6 (KO, PE, SP) U

New Smile Dental Care #02152521012 Norwalk Blvd 562-860-8828 P/T 2 (KO, SP)LANCASTERAlex Buznikov, DDS Corp #0283141331 W Avenue J Ste 201 661-645-1019 P/T 1 (SP, RU, PL)American Bright Dental #00233644810 Elm Ave 661-945-2645 F/T 1 (SP)Boyadjian/Matossian Dtl Corp #01853643845 10th St W Ste 1A 661-948-9646 P/T 1 (AM, TA, SP, PE, RU) U

Bright Now Dental #02113243456 10th St W 661-945-2900 F/T 1 P/T 12 (SP) U

Desert Breeze Dental Care #0135221340 W Avenue J 661-942-1474 P/T 1 (SP)Elite Dental Care #02462644439 North 17T St W #201 661-723-1461 P/T 2 (SP, KO) U

Family Dental Practice #02389944558 10th St W 661-723-1111 F/T 2 P/T 1 (SP)Golden Dental #030150803 W Avenue J 661-948-8100 F/T 1Hi Desert Dental Center #0018191745 W Avenue K Ste C 661-723-5400 F/T 1 P/T 2 (RU, SP, TA) U

Honping Wong, DDS #02781144439 17th St W Ste 103 661-949-0390 F/T 1Kamram Saidara, DDS #3785012030 W Avenue J 661-949-6757 F/T 2 (SP, PE)Smilecare-Lancaster #0015051228 W Avenue K 661-949-1970 F/T 1 P/T 2 (SP) U

LAWNDALEAll Smile Dental Care #02456115228 Hawthorne Blvd 310-679-8000 F/T 1Bay Dental #01288716910 Hawthorne Blvd 310-542-4333 F/T 1 P/T 1 (HI, SP)Hanna Dentistry #01351814314 Hawthorne Blvd 310-676-6400 F/T 2 (AR, SP) U

Henry S Lee DDS #0177474181 Redondo Beach Blvd 310-371-6513 P/T 1 (SP)

Lawndale Dental #02026716128 Hawthorne Blvd 310-370-4511 F/T 3 P/T 10 (SP, TA) U

Maged Nessim, DDS #01750915655 Hawthorne Blvd # A-B 310-675-7111 F/T 1 P/T 2 (AR, SP, TA) U

LEMON GROVEGrove Dental Group #2C78017733 Palm St Ste 105 619-464-7099 P/T 1 (SP)Smileburst Dentistry #2 #0210087040 Broadway # A27 619-667-1088 F/T 1 P/T 2 (SP, TA) U

Loma Linda Bruce Taber, DDS #14830125835 Barton Rd Ste 104 909-796-2299 F/T 2 (KO, RU, SP) U

LOMITAA Dentistry #0018981816 Lomita Blvd 310-326-4117 P/T 1 (KO, SP) U

Narinder Uppal, DDS #13150125107 Narbonne Ave 310-539-8392 F/T 1 (SP) U

Pch Dental #0C61012207 Pacific Coast Hwy 310-534-2633 F/T 1 (SP) U

Shannon Yoon, DDS #00885825124 Narbonne Ave Ste 202 310-530-3260 F/T 1 (SP)LONG BEACHAccu Dental Group #0189766413 E Spring St 562-938-8388 P/T 1 (SP, VI) U

Alan Grant, DDS #0805013620 Long Beach Blvd Ste B6 562-426-6458 F/T 3 P/T 1 (SP, TA, KO) U

Atlantic Dentistry & Braces #0177483530 Atlantic Ave Ste 103 562-988-2700 F/T 2 P/T 1 U

Bashar Komoc, DDS #0245633318 E Anaheim St 562-986-5570 F/T 1 (GE, SP)Beautiful Smiles Dental Care #0116751729 Termino Ave 562-494-8400 P/T 2 (SP) U

Bixby Knolls Dental Group #0196063903 Long Beach Blvd 562-427-2478 F/T 1 P/T 2 (SP, TA, PE)Bondades Family Dental Office #0320416950 N Paramount Blvd 562-531-9711 F/T 1 P/T 2 (HI, SP)Carson Dtl & Cosmetic Ctr #0336741200 E Carson St Ste 300 562-988-7788 F/T 1 (SP) U

Donna Marie Calima, DMD #002517389 Redondo Ave 562-621-9796 F/T 1 (SP, TA) U

Dr Campbell/ Century Dental #0172182211 E 7th St 562-439-6562 F/T 2 P/T 1 (SP, VI) U

E Dental #0264624301 Atlantic Ave Ste 4 562-426-9308 P/T 1 (SP, KO)Family Dental Care #0C63011327 Long Beach Blvd 562-218-5555 F/T 1 P/T 1 (SP, HE) U

Firoz Hakakha, DDS #0C62011183 E Anaheim St 562-599-6600 F/T 1 P/T 1 (SP, HE) U

Gary Trombatore, DDS #0301683840 Woodruff Ave Ste 104 562-425-0545 F/T 2Jasbir Batra DDSInc #000901925 E San Antonio Dr Ste 10 562-428-4678 P/T 1Knolls Dental Group #3883013932 Long Beach Blvd # A 562-427-3890 P/T 1 (SP) U

Kosal Kom, DDS #0126822338 E Anaheim St Ste 108 562-434-9980 F/T 1 (VI)Long Beach Dental Arts #0056106226 E Spring St Ste 200 562-421-3336 P/T 1 (SP) U

Long Beach Dental Group #007631659 Redondo Ave 562-439-0494 F/T 1 P/T 1 (SP)Long Beach Dental! #019416308 Orange Ave 562-436-4214 P/T 1 (SP)

Maged Zaky Nessim DDS., Inc #0028643440 Atlantic Ave Ste 2 562-424-0724 P/T 1 (AR, SP)Mark Cocchi, DDS #3592012865 Atlantic Ave Ste 119 562-426-0778 F/T 1 (GE, IT, SP)Newport Dental #0236483383 Long Beach Blvd 562-424-1600 F/T 2 P/T 8 (SP) U

Omega Family Dental #015864816 W Willow St 562-595-7077 F/T 1 (CH, VI, SP) U

Shamanna Mohan, DDS #0019225399 Orange Ave 562-422-9698 F/T 1 (SP)United Family Dental #000633141 E Willow St Ste P 562-988-2888 F/T 4 (PE, SP, TA, RU) U

Universal Care Dental #1278012360 Pacific Ave 562-595-0731 F/T 6 P/T 8 (SP, VI) U

Universal Care Dental #0027923325 Palo Verde Ave Ste 208 562-429-1642 F/T 3 P/T 5 (SP, TA, VI)Victor De Los Santos, DDS., Inc #0133333712 Atlantic Ave Ste C 562-426-1298 F/T 1 P/T 2 (SP)Village Dental Center Bldg #0840014200 N Lakewood Blvd 562-420-1701 F/T 2 (SP) U

LOS ALAMITOSAshokkumar Mehta, DDS #28340110900 Los Alamitos Blvd 562-596-8888 P/T 2 U

Enhance Dental #0256874300 Katella Ave 562-799-8300 F/T 1 (KO, SP) U

Los Alamitos Dental Arts #1877013724 Katella Ave 562-936-0071 F/T 1 P/T 1Michael Mcwalters, DDS., Inc #0116363662 Katella Ave Ste 206 562-598-7914 P/T 1 (SP) U

LOS ANGELESAdelaida Quingco, DDS #0031531127 Wilshire Blvd Ste 1103 213-250-3998 F/T 1 (SP, TA) U

Adonis Regala Fam Dentistry #0116864065 Whittier Blvd Ste 201 323-268-3877 F/T 1 (SP, TA)Afar & Ghasri Dental Corp #0221036221 Wilshire Blvd Ste 303 323-931-2000 P/T 2 (SP, RU, PE)Afshin Golyad, DDS #01657012340 Sta Mon Blvd Ste 241 310-820-7010 P/T 1 (TA, PE, SP) U

Afsoon Gerayli, DDS., Inc #02167810921 Wilshire Blvd Ste 409 310-824-2624 F/T 1 (PE) U

Airport Center Family Dental #0075385304 W Century Blvd 310-215-1455 P/T 1 (SP) U

Alegria Dental Center #0295474214 Beverly Blvd Ste 209 213-384-8400 F/T 2 (AM, AR, RU, SP, TA) U

Alex Buznikov, DDS Corp #02814511600 Wilshire Blvd Ste 10 310-415-1649 F/T 1 (PL, RU, SP) U

Ali Khosrovani DDS #0238904905 York Blvd 323-255-8774 F/T 1 (AM, PE, SP)Alina Oganyan, DDS., Inc #0028681727 N Vermont Ave Ste 109 323-644-3366 F/T 1 (AM, RU) U

Alvarado Family Dental Center #003544811 S Alvarado St 213-383-3314 P/T 2 (SP) U

American Dental #0245462033 E Florence Ave 323-583-8896 P/T 1 (RU, SP)American Dental #0245502716 N Broadway Ste 214 323-221-5931 P/T 1 (SP, RU)Amy Iwata, DDS #0124413756 Sta Rosalia Dr Ste 504 323-293-2600 F/T 1 (SP, JA) U

Anthony Milanez, DDS #0137875670 Wilshire Blvd Ste 1710 323-931-9019 F/T 1 U


To enroll in the KPIC DENTAL insurance plan, please complete the enrollment form in this brochure (page 7-and enclose the first month’s payment (payable to Wolfpack Insurance Services, Inc.). Return the enrollment form and the first month’s payment by December 21, 2010 to:

Wolfpack Insurance Services, Inc.P.O. Box 720Belmont, CA 94002-0720

Make checks payable to Wolfpack Insurance Services, Inc.

Staple your check in the space provided on this form. Use only a check that corresponds to the banking information you have provided.

Payment instructions: Payments are due retroactively to the month you and/or dependents enrolled in the Kaiser Federal Employee Dental Plan plus one month in advance. After payment and application are received, the first automatic payment will occur on the 10th of the following month and each month thereafter.

Remember —

• If you are currently a member of Kaiser Permanente, please include a copy of your Kaiser Permanente ID card.

or

• If you are now enrolling in Kaiser Permanente, please include a copy of your Medical Enrollment Form (Form 2809).

30 7

EN

RO

LL

ME

NT

FO

RM

Your full name Social security number

Kaiser Permanente Medical Record number

Mailing address

City State ZIP

Male Female Date of birth / / Phone number ( ) —








Enrollment — Coverage not elected below will be assumed refused if not specifically refused.

Yes, I would like to enroll in the Kaiser Permanente Insurance Company (KPIC) Group Dental Plan for Federal Employees. I understand that enrollment is voluntary. By electing to enroll, I agree to participate in the KPIC Trust (and/or any successor Trust), which holds the KPIC Group Dental Policy. I understand that to be eligible for the Plan, I must be enrolled along with any of my dependents to be covered, in Kaiser Permanente’s Traditional HMO Plan for Federal Enrollees. I further understand that my continued eligibility, and that of my covered dependents, is contingent on our continued enrollment in Kaiser Permanente’s Traditional HMO Plan for Federal Enrollees. I also understand that some covered dental services are subject to waiting periods. I certify that to the best of my knowledge and belief, any information disclosed on this enrollment form, is accurate and that my answers are correct, true and complete.

No, I do not wish to participate. I understand that I will not be entitled to any benefits under the KPIC Group Dental Plan and will not be able to enroll until the next annual renewal period. (Coverage not elected will be assumed refused, even if not specifically refused.)

Signature of enrollee _________________________________________________________________________________ Date __________________________

KPIC — Enroll — 9793 (rev. 9/2008)

GROUP DENTAL ENROLLMENT FORM

Enrollment Information — Failure to accurately complete the questions on the enrollment form may delay the effective date of your coverage under the KPIC Dental Insurance Plan.

Instructions: Please complete this Group Dental Enrollment Form and return a signed copy with your first month’s payment by December 21, 2010 to:Wolfpack Insurance Services Inc.

P.O. Box 720Belmont, CA 94002-0720

KAISER PERMANENTE INSURANCE COMPANYOakland, California

or

Aram Arakelyan, DDS #0183732426 W 8th St Ste 209 213-381-3900 P/T 1 (RU, AM, SP)Arturo V Hernandez, DDS #0263603120 W 6th St 213-351-7661 F/T 1 (SP, TA)Barry Kashfian, DMD #1256012080 Century Park E Ste 1406 310-553-1578 P/T 1 (SP, TA)Benji Behroozan, DDS #3655015255 W Sunset Blvd 323-463-7252 F/T 1 P/T 1 (PE, SP)Beverly Drive Dental Group #0127951125 S Beverly Dr Ste 750B 310-277-7645 P/T 1 (PE, SP) U

Beverly Hills Family Dental #0095381125 S Beverly Dr Ste 400 310-286-7447 F/T 1 (PE, SP) U

Boyle Heights Family Dntstry #0214812110 E Cesar E Chavez Ave 323-268-8308 F/T 1 (SP, KO)Brentwood Dental Group #00250711980 San Vte Blvd Ste 660 310-979-8345 P/T 1 (PE, SP, TA) U

Bright Now! Dental #0156474251 Crenshaw Blvd 323-295-5577 F/T 6 P/T 8 (SP)Brighter Dental #0018146221 Wilshire Blvd Ste 507 323-939-7899 P/T 1 (PE, SP, TA)Brite Dental #0291773530 Wilshire Blvd Ste 150 213-487-7771 P/T 2 (KO, SP) U

Byung Chul Kim, DDS #270601765 N Virgil Ave 323-665-5887 F/T 1 (KO, SP)California Dental Care #15210111628 Sta Mon Blvd Ste 101 310-207-1060 P/T 1 (SP) U

Calm Dental #031387525 S Olive St 213-624-3333 P/T 1 (PE, SP) U

Centro Medico/Dental Familiar #000635514 E Washington Blvd 213-749-3934 P/T 2 (RU, SP) U

Chantiste Beal, DDS #0303735010 S La Brea Ave 562-381-5626 F/T 1Cheryl Bingham, DDS #34900111905 S Central Ave Ste 203 323-564-7504 F/T 1 (SP)Chinatown Service Center #018954767 N Hill St Ste 200 213-808-1790 F/T 1 (CA, CH, SP, VI)Cohen Dental #0148609188 W Pico Blvd 310-276-9966 P/T 1 (PE, SP) U

Commerce Dental #0129475542 Whittier Blvd 323-722-8700 F/T 1 P/T 1 (RU, SP) U

Continental Dental Group #173201600 W Manchester Ave Ste 2 323-750-1582 P/T 1 (SP) U

Crown Dental Group #0103196907-A La Tijera Blvd 310-645-0336 P/T 1 (KO, SP) U

Crystal Dental #0280122206 S Figueroa St 213-748-8448 F/T 1 P/T 1 (CH, PE, SP) U

Culver Del Rey Dental Office #21190112202 W Washington Blvd 310-915-9797 F/T 3 P/T 1 (SP) U

Cypress Dental Clinic #0028652135 Cypress Ave 323-223-0731 F/T 1 (SP) U

Dan Benyamini, DDS #0006371826 W 7th St 213-484-6660 F/T 1 (PE, SP) U

David Daneshrad, DDS #12020111850 Wilshire Blvd Ste 101 310-477-8766 F/T 1 (SP, TA) U

Davis Famili DDS, Magd Inc #01994611500 W Olypmic Blv #508 310-477-7744 P/T 1 (SP, PE, FR) U

Dental Central Group #0109343009 S Vermont Ave 323-730-7200 P/T 1 (SP, PE, TA) U

Dental Ctr of Highland Park #0000345807 N Figueroa St 323-982-0999 P/T 2 (SP) U

Dental Ctr of W Los Angeles #0165741964 Westwood Blvd Ste 145 310-474-5575 F/T 1Dental Pros #011114906 N Vermont Ave 323-953-7700 P/T 3 (SP) U

Dentology Family Dentl & Braces #01854611444 W Wash Blvd Ste B 310-572-6167 F/T 1 P/T 2 (SP, PE)Devang Gandhi Dental Corp #3533012500 W Florence Ave 323-750-2082 F/T 1 (HI, SP) U

Dr Makar Family Dentistry #0124703875 Wilshire Blvd Ste 1104 213-380-0200 F/T 1 (SP, AR)Dr Mehtas Family Dentistry #0250644576 Whittier Blvd 323-261-0369 F/T 1 (HI, SP)Dr Namian Family Dentistry #001749609 S Atlantic Blvd 323-980-9768 F/T 1 P/T 1 (PE, SP) U

Dr Tsolakyans Dental Office #0015093161 Los Feliz Blvd 323-663-2606 F/T 2 (AM, PE, RU, SP) U

East Los Angeles Fmly Dntstry #0183694410 Whittier Blvd 323-881-0881 P/T 1 (SP)Eastern Dental Center #0214403346 N Eastern Ave 323-227-1800 P/T 1 (SP, CH, VI)Elyson And Assili #382501745 S Kern Ave 323-263-2125 P/T 2 (SP) U

Emily Lee, DDS #3660013756 Sta Rosalia Dr Ste 200 323-299-2994 F/T 1 (SP)Excel Dental Care Inc #0313983980 Glenfeliz Blvd 323-663-2050 P/T 2 (AM, RU, SP) U

Family Dental Care #02519012012 W Washington Blvd 310-390-7981 F/T 1 (SP, AR)Farid Pakravan, DDS., Inc #3283012604 S Vermont Ave Ste 109 323-731-3333 F/T 1 P/T 1 (SP) U

First Family Dental Group #0248223460 Wilshire Blvd Ste 104 213-383-3460 P/T 1 (KO, SP)Florence Compton Dental Group #1847017110 Compton Ave 323-585-5588 F/T 1 P/T 1 (RU, SP) U

Florence Dental Group #0337971575 E Florence Ave Ste A 323-537-4121 F/T 1 (PE, SP) U

Forever Smile Dental Care #0215026200 Wilshire Blvd Ste 1604 323-634-9004 P/T 1 (PE, SP, HE) U

Fred Nayssan, DDS #00232610350 Sta Mon Blvd Ste 190 310-557-1704 F/T 2 (SP) U

Gentle Care Dental Inc #2283013500 Whittier Blvd Ste 101 323-264-8834 F/T 1 (SP) U

Gentle Family Dentist #0276945207 Whittier Blvd 323-269-0266 F/T 2 (SP) U

Gewaid Professional Dtl Corp #010260231 W Vernon Ave Ste 107 323-233-5906 F/T 1 (AR, SP)Green Dental #0281443054 W 8th St Ste 106 213-387-2864 F/T 1 (SP, KO) U

Happy Dental Care #0112935534 York Blvd 323-344-0444 F/T 2 (AM, PE, SP)Hasmik Ambartsumyan, DDS #0175295222 1/2 W Sunset Blvd 323-666-2222 F/T 1 (AM, RU) U

Hengameh Anaraki, DDSInc #0223943875 Wilshire Blvd Ste 901 213-383-2700 F/T 1 (SP, PE)Highland Park Dental Group #1210015740 1/2 York Blvd 323-257-0915 F/T 1 P/T 1 (RU, SP)Hollywood Family Dentist #0287118205 Sta Mon Blvd Ste 12 323-650-1001 F/T 2 (AM, RU, SP)

Hollywood Smile Dental Center #3752018182 W Sunset Blvd Ste 202 323-654-1100 F/T 1 P/T 1 (GE, RU, SP) U

Hollywood Vine Dental Office #0019155280 Hollywood Blvd 323-469-9169 P/T 1 (AM, RU, SP)Ida Ganapolsky, DDS #0086883356 E Olympic Blvd 323-269-5221 F/T 1 (RU, SP)Impressive Dental Center #0162021435 S Vermont Ave 213-739-3096 P/T 1 (SP, HI)James Black, DDS #0059013015 Crenshaw Blvd 323-731-0801 F/T 4 (KO, SP) U

Jeffrie Maneepetasut, DMD Inc #0203214606 Hollywood Blvd Ste B 323-663-3850 F/T 1 (SP, TH)Jocelyn Capistrano, DDS #002866628 N Vermont Ave Ste 5 323-644-3650 F/T 1 (TA)John M Legaspi, DMD #0185946075 S Vermont Ave 323-758-3131 P/T 1 (SP, TA)Kais Chebbi DDSInc #0248125877 S Vermont Ave 323-759-1523 F/T 2 P/T 1Kenneth Chang, DDS #2199014026 W Olympic Blvd 323-930-1744 F/T 1 (SP)Keromina Dental Office #0023324777 Fisher St 323-268-3395 F/T 1 (SP, AR)Khashayar Khodadadi, DDS #02951711900 S Avalon Blvd 323-834-0100 P/T 1 (SP, PE) U

Krest Family Dental #3C54018740 S Sepulv Blvd Ste 130 310-410-9494 F/T 1 P/T 2 (EI, SP, TA) U

La Brea Family Dental #0321873400 S La Brea Ave 323-734-2284 P/T 2 (KO, SP) U

La Paz Clinic #0189531107 S Alvarado St Ste 102 213-380-9999 F/T 3 (HE, PE, SP) U

Ladera Dental Group #0185935814 Rodeo Rd 310-836-7200 F/T 1 (FR, HI, SP)Le Chic Dentist #0267793755 Sawtelle Blvd 310-398-5400 F/T 1 P/T 1 (SP, PE) U

Leslie Laddaran, DDS #3562012105 Beverly Blvd Ste 101 213-484-1288 F/T 2 P/T 1 (SP, TA, CH) U

Lloyd E Stoll, DDS., Inc #0331531828 E Cesar E Chavez Ave 323-268-1805 F/T 1 (SP) U

Manoj Amin, DDS #3455012613 W Sunset Blvd 213-484-1845 F/T 1 U

Manuel Lazo Jr., DDS #0146153827 W Sunset Blvd Ste A 323-660-5630 F/T 1 (TA)Maria P Bernardo, DDS #0182594331 W Sunset Blvd 323-660-2011 F/T 1 (SP, TA) U

Mark A Moses, DDS #0260851839 W Imperial Hwy 323-757-1761 F/T 1 (SP)Mark Laska, DDS #0096933460 Wilshire Blvd Ste 210 213-386-3348 F/T 2 P/T 1 (SP, TA, KO) U

Mehrdad Makhani, DDS #3725016200 Wilshire Blvd Ste 1606 323-933-7744 F/T 1 (PE, SP) U

Michael Schneider, DMD #03326610921 Wilshire Blvd Ste 809 310-208-6813 F/T 1 P/T 1 U

Nelson Walker, DDS #3201013756 Sta Rosalia Dr Ste 317 323-290-5340 F/T 1 (SP) U

Newport Dental #0045961155 N Vermont Ave 323-660-8111 F/T 2 P/T 16 (SP, VI) U

Newport Dental #0087273635 E 1st St 323-269-7367 F/T 5 P/T 3 (AR, CH, SP)Normandie Dental Clinic #0214241690 W Adams Blvd 323-730-0924 F/T 1 (SP, RU, AM, KO)

Ojan Ghalchi, DMD #009138281 Columbia Ave 213-483-3020 F/T 1 (PE, SP) U

Parastoo Farhoodi, DDS #3561013169 Barbara Ct 323-876-6440 F/T 1Patrick Clerk, DDS #0422011200 Wilshire Blvd Ste 205 213-481-1252 F/T 1 (SP) U

Personal Dental Office #0148586222 Wilshire Blvd Ste 103 323-933-4444 P/T 1 (PE, RU, SP) U

Pico Dental Group #0122471561 W Pico Blvd 213-251-9994 F/T 1 (SP, PE)Pico La Cienega Dental #0059548530 W Pico Blvd 310-854-6107 F/T 1 (PE, SP, AM)Premier Dental Clinic Inc #0175311115 Colorado Blvd 323-255-4600 P/T 1 (AM, PE, SP)Ramin Ravaei, DMD #0299551835 S La Cnega Blvd Ste 200 310-836-0300 F/T 2 (SP, TA, RU, PE)Ramin Tour DDSInc #006734907 N Virgil Ave 323-661-8384 P/T 1 (SP, PE, TA)Roberto Parra, DDS #023304 279 S Atlantic Blvd # B 323-266-0899 F/T 1 P/T 1 (SP) U

Sami Nouhad, DDS #1754017080 Hollywood Blvd Ste 817 323-466-3541 F/T 1 (AR, FR, SP) U

Santa Clara Dental #028241600 W Manchester Ave Ste 1 323-753-2361 F/T 1 (SP)Santa Monica Dental Assoc #02998311775 Santa Monica Blvd 310-444-1818 F/T 1 (PE, SP) U

Shahram Sayedna, DDSInc #0169081700 Westwood Blvd 310-470-3095 F/T 1 (GE, PE)Shauna Lee, DDS #0027884146 E Olympic Blvd Ste F 323-269-8007 F/T 1 (SP) U

Sid Solomon, DDS #3934011620 Westwood Blvd 310-475-5598 P/T 1 (FR, PE, SP)Silverlake Dental #0136822390 Glendale Blvd 323-913-9900 F/T 1 (SP, AM, PE, TA) U

Smile Makers #024589998 S Robrson Blvd Ste 103A 310-358-1200 F/T 1 (PE, SP) U

Smilecare-Los Angeles #0039511440 W Manchester Ave 323-753-1141 F/T 2 P/T 2 (FR, KO, SP) U

Smiles R Us Dental Care #01257912756 W Washington Blvd 310-574-8574 F/T 1 (SP, PE)St George Dental Clinic #0064716767 W Sunset Blvd Ste 25 323-469-8816 P/T 1 (RU, SP, AR) U

Steven Stanley, DDS #3729016221 Wilshire Blvd Ste 307 323-931-1446 F/T 1 (RU)Theodore Stomel, DMD #0143286333 Wilshire Blvd Ste 208 323-653-1300 P/T 2 (RU, PE)Total Care Dental & Ortho #0268455703 S Vermont Ave 323-751-5600 F/T 2 P/T 2 (SP) U

United Family Dental Group #1980015109 Whittier Blvd 323-265-2222 F/T 1 (SP, PE) U

Universal Care Dental #1276011111 W 6th St Ste 120 213-895-0009 F/T 4 P/T 4 (SP, TA) U

Universal Care Dental #0280152839 N Eastern Ave 323-987-1020 F/T 3 P/T 3 (SP, VI)Venice Dental Group Inc #00521012456 Venice Blvd 310-390-2423 F/T 2 (AR, SP)Vermont Dental Care #0122098914 S Vermont Ave 323-750-3370 F/T 1 P/T 1 (PE, SP)Vermont Dental Grp Implnt Ctr #012342732 S Vermont Ave 213-386-3366 F/T 1 (KO, SP, TA) U

Victoria Olshansky, DDS., Inc #0165021136 N Fairfax Ave 323-650-6936 F/T 1 (PL, RU)Villacis Dental Corp #02923012027 Venice Blvd Ste A 310-313-5150 P/T 1 (SP)Warren Gerosa, DDS #0170978540 S Sepulv Blvd Ste 1212 310-645-2886 P/T 1 U

Watts Healthcare Corporation #32850110300 Compton Ave 323-357-6600 F/T 1 P/T 1 (SP) U

West Coast Dental #0090171423 E Gage Ave Ste A 323-983-4000 P/T 1 (PE, SP) U

West Coast Dental #0158315162 Whittier Blvd 323-415-6161 P/T 1 U

West Coast Dtl Grp 6th Street #0175341725 W 6th St 213-413-5151 P/T 1 (SP) U

Westwood Dental #02149510884 Sta Mon Blvd Ste 401 310-446-4410 F/T 1 (PE, SP) U

Westwood Dental Care #02825410921 Wilshire Blvd Ste 601 310-208-8551 F/T 1 U

Westwood Smile Design #03349512301 Wilshire Blvd Ste 20 310-207-0606 P/T 1 (PE, SP) U

Westwood Village Dental #023825 951 Westwood Blvd 310-824-2225 F/T 1 P/T 1 (SP) U

Whittier Dental Group #0017472901 Whittier Blvd Ste B 323-526-1992 P/T 2 (PE, SP) U

William Faulkner, DDS #1835015870 Crenshaw Blvd Ste 513 323-292-0231 F/T 1 (SP) U

William Ginzburg, DDS #0C72013130 S Sepulveda Blvd Ste D 310-268-0646 F/T 1 (SP) U

Wilshire Center Dental Group #0445013932 Wilshire Blvd Ste 100 213-386-3336 F/T 6 P/T 4 (SP) U

Wilshire Dental Care, #0103446200 Wilshire Blvd Ste 1508 323-938-6137 F/T 1 P/T 2 (RU, SP, TA) U

Wilshire Dental Group #0124406200 Wilshire Blvd Ste 1104 323-525-1819 F/T 1 (RU, AM, PE, CH)Wilshire Smile Studio Dtl Grp #0016646200 Wilshire Blvd Ste 1609 323-937-5773 F/T 1 P/T 1 (PE, TA) U

Winnie Tan, DDS #0061892621 E 1St St 323-268-9386 F/T 1 (JA, SP)Woodside Dental #00254010921 Wilshire Blvd Ste 505 310-824-0055 F/T 1 P/T 2 (PE, SP, TA)Yiwen Liu, DDS #02465711103 Venice Blvd 310-559-9191 F/T 1 (SP, CH)LYNWOODCristina Rodriguez, DDS #0215063737 Mlk Blvd # 375 310-639-9191 F/T 1 (SP)Pacific Smiles Dental Center #0098633150 E Imperial Hwy Ste 200 310-608-7777 F/T 1 P/T 3 (AM, EI, SP) U

Universal Care Dental #3C43013680 E Imperial Hwy Ste 100 310-761-8100 F/T 6 P/T 7 (EI, SP, TA, VI) U

West Coast Dental #0042039910 Long Beach Blvd Ste A 323-563-8900 P/T 1 (SP) U

MANHATTAN BEACHManhattan Beach Dentistry #2C2701500 S Sepulveda Blvd Ste 210 310-372-8188 F/T 1 P/T 1Manhattan Village Dental Grp #2C14011200 Rosecrans Ave Ste 210 310-414-0620 P/T 1 (SP) U

MARINA DEL REYMarina Dental Center #11150113155 Mindanao Way 310-821-2611 F/T 1 (RU, TA, SP, VI) U

Marina Dentistry Inc #0214024292 Lincoln Blvd 310-578-5000 F/T 1 P/T 2 (PE, SP, TA) U


6 31

MAYWOODMaywood Dental Care #0264636059 Atlantic Blvd 323-560-3131 F/T 1 (KO, SP)New Millennium Dental Group #0168116021 Atlantic Blvd 323-560-6096 P/T 1 (RU, SP) U

Southeast Dental Group #1596014332 Slauson Ave 323-588-2141 F/T 2 P/T 3 (GE, SP, TA, CH) U

Summer Dental Group #0319524201 Slauson Ave 323-560-4658 F/T 1 P/T 1 (SP) U

Summer Verano Dental Group #0264614201 Slauson Ave 323-560-4658 P/T 1 (SP, TA)MENIFEEMenifee Smiles Dentistry #02685330406 Haun Rd Ste 740 951-679-4624 F/T 1 P/T 2 (SP) U

Menifee Valley Dental Group #18320126910 Newport Rd Ste B 951-672-9457 P/T 1 (SP, PE)Quynh Tran Nguyen Dent Corp #03166327174 Newport Rd Ste 1 951-723-8801 P/T 1 (VI) U

MEXICALIDenticenter #351701460-1 Avenida Modero 760-235-4162 F/T 1 (SP)MIRA LOMAGateway Dental of Eastvale #01117412571 Limonite Ave Ste 230 951-360-3444 F/T 1 P/T 1 (SP) U

Limonite Dental Group #02669612363 Limonite Ave Ste 960 951-371-7711 F/T 1 (CH, SP, VI)Mira Loma Dental Centers #00254611058 Limonite Ave 951-737-6005 F/T 1 (HI, SP) U

Mira Loma Smiles #0226116445 Pats Ranch Rd Ste G 951-808-5881 P/T 2 (SP) U

MISSION HILLSArjomand Madadshahi, DDS #01573715501 Sanfernando Mission104 818-365-8600 F/T 1 (SP, PE) U

Bright Dental Group #02149115534 Devonshire St Unit 108 818-830-4100 P/T 1 (PE) U

Devonshire Dental #02139015300 Devonshire St Ste 6 818-894-6411 F/T 1 P/T 1Parviz Kohanoff, DDS #35550111550 Ind Hills Rd Ste 281 818-361-8777 F/T 1 (PE, SP) U

MISSION VIEJOAmazing Smiles Dental Care #03350526800 Crown Valley Pkwy 385 949-388-3878 F/T 1 (PE, SP, TA) U

Appealing Dentistry Msn Viejo #27100126302 La Paz Rd Ste 211 949-766-7687 F/T 1 (HE, PE, PL, RU, SP) U

Avalon Dentistry #02521127725 Snta Mrgarita Pky #270 949-951-0951 F/T 2 (PE, SP, TA, VI) U

California Dental Care #01561128201 Marguerite Pkwy Ste 10 949-347-0302 P/T 1 (JA, PE, SP) U

Gateway Dental Group #02330024000 Alicia Prkwy #34 949-707-7000 F/T 1 (PE) U

Gentle Dental Mission Viejo #00887725523 Marguerite Pkwy Ste C 949-768-1800 F/T 3 P/T 2 (AR, GE, HI, PE, SP) U

James Vartanian, DDS., Inc #02289126302 La Paz Rd Ste 203 949-586-5669 F/T 1 U

Marguerite Dental Care #01994827871 Medical Ctr Rd #165 949-364-2529 F/T 1 (FR, PE, SP) U

Mission Dental Group #01427126032 Marguerite Pkwy # A-1 949-582-8400 P/T 2 (SP) U

Mission Viejo Dental #02140823482 Alicia Pkwy 949-581-0090 F/T 5 P/T 7 (IN, PE, SP, VI) U

Mission Viejo Dental Assoc #00186625522 Marguerite Pkwy # 100 949-586-6200 F/T 1 P/T 1 (CH, SP) U

New Smile Dental #02168724481 Alicia Pkwy Ste B3 949-586-9800 F/T 1 (PE, SP) U

Raed Fawaz, DDS #01715226902 Oso Pkwy Ste 190 949-582-9206 F/T 1 (SP)Saddle Back Dental Ctr #02331323166 Los Alisos Blvd # 230 949-457-0223 F/T 1 (AR, PE, TA) U

Trabuco Dental #03310227725 Sta Margarita Pkwy 261 949-597-2444 P/T 1 (AR, SP)MONROVIAFoothill Dental Center #155501154-A W Foothill Blvd 626-305-5722 P/T 1 (SP, VI) U

MONTCLAIRAmiel Patel, DDS #3C25014921 Moreno St 909-625-3865 F/T 1Central Family Dentistry #1795019197 Central Ave Ste C 909-398-1107 F/T 1 (CH, SP, TA)Johnson Family Dentistry #1991019645 Monte Vista Ave Ste 305 909-621-6002 F/T 2 (SP)MONTEBELLODaniel Farkas, DDS #2109013301 W Beverly Blvd 323-722-6766 F/T 4 P/T 1 (SP) U

Dental Ville #013595833 W Whittier Blvd 323-266-1000 P/T 2 (SP)Dr Davids Family Dentistry #2393012100 W Beverly Blvd 323-724-9536 F/T 1 (SP) U

Dr Gregory Robins Fmly Dstry #019967604 N Montebello Blvd # B 323-721-0799 F/T 1 P/T 1 (CH, GE, KO, SP) U

Greenwood Dental #1569011214 1/2 S Greenwood Ave 323-728-3272 F/T 1 (FR, SP) U

Margaret Wu, DDS #0224181717 W Beverly Blvd 323-724-9326 F/T 1Montebello Dental Associates #013239711 W Whittier Blvd 323-278-0170 P/T 1 (PE, SP, AM) U

Montebello Dental Center #0251882332 W Whittier Blvd 323-838-8055 F/T 1National Dental #013236249 E Beverly Blvd Ste A 323-726-7500 F/T 1 P/T 1 (SP, VI) U

S Ghazarian, DDS #363901433 N Montebello Blvd 323-722-2922 F/T 1 (AM, PE, SP) U

Smilecare-Montebello #0039521451 N Montebello Blvd 323-724-9955 F/T 2 P/T 5 (SP) U

Tigran Hovannisyan, DDS #0211072059 W Whittier Blvd 323-727-9898 F/T 1 (AM, RU, SP) U

Vista Sol Dental #0140171000 W Whittier Blvd 323-346-0555 P/T 1 (FR, PE, SP) U

MONTEREY PARKA Gary Kelleyan DDS #021887616 N Garfield Ave Ste 404 626-280-4122 F/T 1 (SP)Central Dental #0037082111 S Atlantic Blvd 323-261-9999 P/T 1 U

Golden Dragon Family Dntry #026502871 S Atlantic Blvd 626-284-4200 F/T 2 (SP, CH)Isaac Chen, DDS #2396012071 S Atlantic Blvd Ste F G 323-260-7878 F/T 1 P/T 2 (CH, KO, SP) U

Pacific Dental Group #1964012016 S Atlantic Blvd 323-725-6797 P/T 1 (AM, IT, PE, SP) U

MOORPARKMoorpark Dental Group #020308718 W Los Angeles Ave # 3 805-529-1743 P/T 1 (SP) U

Moorpark Smiles Dental #028898144 W L.A. Ave Ste 114 805-553-1980 P/T 1 (SP) U

MORENO VALLEYBright Now! Dental #01050912420 Day St Ste B4 951-656-6538 F/T 2 P/T 20 (CH, SP, TA, VI) U

California Dental Office #00913012800 Heacock St Ste A1 951-247-2688 F/T 2 P/T 2 (CH, SP, VI)Community Dental of Dr Chi #00353111875 Pigeon Pass Rd Ste B9 951-488-8688 P/T 1 (CH, SP)Dtl Assoc/Moreno Valley Mall #39630122500 Town Cir Ste 2074 951-697-6800 F/T 1 (SP)Family Dentistry #03100323962 Alessandro Blvd Ste R 951-697-8888 F/T 1 U

Harry Karna, DDS #03120012264 Perris Blvd 951-485-2800 F/T 1 (HI, SP, TA) U

James Dickey, DDS #34620124266 Postal Ave Ste 100 951-242-2600 F/T 1Moreno Dental Care #02962423750 Alessandro Blvd # O102 951-656-0088 F/T 1 P/T 1 (KO, SP, TA) U

Robert Silvola, DDS #27330112810 Heacock St Ste B103 951-242-3441 F/T 1 (SP)Smilecare-Moreno Valley #00310512125 Day St Bldg N Ste 211 951-222-2000 F/T 1 P/T 3 (SP)St Patrick Dental Clinic #01583724655 Sunnymead Blvd 951-242-6088 P/T 2 (TA) U

Stoneridge Dental Group #02246927110 Eucalyptus Ave Ste A 951-616-1759 P/T 1 (SP) U

Towngate Family Dental #03312712625 Frederick St Ste F4 951-697-7750 F/T 1 U

MURRIETACal Oaks Dental Excellence #03089540414 Calif Oaks Rd Rd#A 951-304-7472 P/T 1 (PE, SP) U

Copper Canyon Smiles #01760523771 Washington Ave # H1-02 951-691-5096 P/T 1 (SP) U

Friendly Dental Center #02613739252 Winchester Rd Ste 117 951-894-7769 P/T 1 (VI, SP, PE) U

Madison Springs Dental #2C590125285 Madison Ave Ste 107 951-698-3585 F/T 2 P/T 1 (SP)Margarita Dental Group #01741039400 Murrieta Ht Sprs #123B 951-461-7470 P/T 1 (SP, CH, VI)Murrieta Dental Excellence #02836840165 Mur Ht Spgs Rd Ste M 951-696-2515 P/T 1 U

Murrieta Dental Group #0C220140770 California Oaks Rd 951-677-3078 P/T 2 (SP)Murrieta Dental Group #00316525395 Madison Ave Ste 103 951-696-5660 P/T 3 (SP, VI)Murrieta Family Dental Group #3C860140643 California Oaks Rd 951-677-7779 P/T 2 (SP)Plaza Dental Group #01777940484 Mur Ht Spgs Rd Spc Gs 951-461-4306 F/T 1 P/T 1 (SP) U

Watanabe & Espeleta Prof Dtl #01312139209 Winchester Rd 951-304-1348 F/T 1 P/T 1 (SP) U

NATIONAL CITYArtemio F Palaganas, DDS #0121651341 E 8th St Ste D 619-474-8441 F/T 1 (SP, TA)Richard Cervantes, DDS #3551012016 Highland Ave 619-477-3770 F/T 1 (SP, TA)South Coast Dental #012746400 Mile Of Cars Way # 400 619-477-1970 F/T 1 (SP)Thomas Toma, DMD #1812013460 Highland Ave Ste D 619-420-1100 F/T 2 (SP, TA)Town And Country Dental #0C23011536 Sweetwater Rd Ste E 619-477-4945 P/T 1 (SP, PE, GE)

NEWBURY PARKQuynh Tran Nguyen, DMD #0155931000 Newbury Rd Ste 138 805-498-8856 P/T 1 (VI) U

Steven Destler, DDS #171201587 N Ventu Park Rd Ste C 805-499-1253 F/T 1 P/T 1 (SP) U

NEWHALLCanyon Country Dental Group #00860526877 Sierra Hwy 661-251-2002 F/T 2 (SP, VI) U

Gabriel Henao, DDS #03113325044 Peachland Ave Ste 100 661-287-4352 F/T 1 (SP) U

Jerrold Singer, DDS #03235025061 Peachland Ave 661-255-7530 P/T 2Lyons Dental Care #00853624036 Lyons Ave 661-255-1015 P/T 2 (AM, PE, SP) U

Lyons Dental Place #02758023238 Lyons Ave 661-259-0600 F/T 1 P/T 1 (TA) U

Mitra Simanian, DDS., Inc #01482923206 Lyons Ave Ste 203 661-255-7338 P/T 1 (AM, PE, RU, SP) U

NEWPORT BEACHAmit Shah, DDS #013066355 Placentia Ave Ste 205 949-646-0818 F/T 1 (HI)Coastal Image Dental #0165443991 Macarthur Blvd Ste 228 949-863-0988 F/T 2 (CH, SP) U

Image Dental #0295961310 Bison Ave 949-760-0363 F/T 1 (VI) U

Joseph Di Caprio, DDS #32780120072 Sw Birch St Ste 150 949-752-2012 F/T 1 (SP)Newport Beach Dental #1258011501 Superior Ave Ste 100 949-650-6772 F/T 3 U

Newport Smiles #0216913333 W Coast Hwy Ste 303 949-642-1033 F/T 2 (PE, SP) U

Newport Smiles #0224143333 W Coast Hwy Ste 303 949-642-1033 F/T 1 (PE) U

Omid Haronian, DDS #0299511901 Westcliff Dr Ste 6 949-646-2481 F/T 1 (SP, PE)NIPOMONipomo Dental Arts #028317255 N Wilson Ave Ste D 805-929-3219 F/T 1NORCOHamner Dental Group #015152140 Hidden Valley Pkwy 951-898-8673 P/T 2 (HI, SP) U

Hidden Valley Dentistry #0264031161 Hidden Valley Pkwy #106 951-582-0200 F/T 1 (SP, PE)Norco Dental Practice #0069841260 Hamner Ave Ste C D 951-279-5200 F/T 2 P/T 2Norco Family Dental #1422012031 River Rd 951-372-9094 P/T 1 (PE, SP) U

NORTH HILLSDental Solutions #0075639146 Sepulveda Blvd Ste A 818-830-7000 P/T 1 (SP, TA) U

West Coast Dtl Grp N Hills #02212315350 Nordhoff St Ste A 818-672-8228 F/T 1 P/T 1 (SP, PE)NORTH HOLLYWOODAshok Gandhi, DDS #0133165942 Lankershim Blvd 818-985-7479 F/T 1 (HI, SP, TA) U

Daniel Boudaie Family Dentist #00279710941 Victory Blvd 818-509-1967 F/T 1 (SP, TA, AM, PE) U

Dental Plus California #0196416512 Laurel Canyon Blvd 818-623-9000 P/T 4 (SP) U

Family Dentistry #00166711436 Vanowen St 818-503-9697 F/T 1 P/T 1 (RU, SP)Hamlin Dental Group #00354612509 Oxnard St Ste 201 818-285-5757 P/T 2 (AM, SP)

Hersel Hanasab, DDS #01565412926 Sherman Way 818-765-4422 F/T 1 P/T 1 (PE, SP) U

Julian Gershfeld, DDS #3498015160 Vineland Ave Ste 105 818-761-8899 P/T 1 U

Magnolia Family Dentistry #02206311300 Magnolia Blvd Unit 5 818-980-7222 F/T 1 P/T 1 (RU, SP) U

Media District Dentistry #01888510732 Riverside Dr 818-760-9494 F/T 3 P/T 1 (PE, SP) U

Noho Dental Group #03265211126 Chandler Blvd 818-432-8300 P/T 2 (PE, RU, SP) U

North Hollywood Dental Grp #02112912125 Vanowen St Ste 2 818-764-4679 P/T 1 (AM, PE, SP, TR)Pacific Dental Group #0028406801 Lankershim Blvd Ste 101 818-764-0718 P/T 1 (RU, SP) U

Premier Dental Clinic #0199864648 Lankershim Blvd 818-505-0520 P/T 1 U

Santo Tomas Dental Group #02956012115 Saticoy St 818-759-1001 F/T 3 P/T 1 (SP, PE) U

Spectrum Dental Care #02176813112 Sherman Way 818-982-6162 F/T 1 P/T 1 (RU, SP) U

Star Smile Dental Grp #02385811404 Victory Blvd 818-508-7000 F/T 1 (SP, TA) U

Unique Smile Dental #0267684789 Vineland Ave Ste 202 818-761-4545 F/T 1 (AM, PE)NORTHRIDGEAt Ease Dentistry #02956711155 Tampa Ave 818-363-3382 F/T 1 (AM, RU, SP) U

Babak Kohanoff, DDS #37880118250 Roscoe Blvd Ste 225 818-349-9151 F/T 1 (SP, PE)Bharati Desai, DDS #3659018954 Reseda Blvd Ste 100 818-701-3010 F/T 1 (SP, HI)Carmen Magpantay, DDS #02717810321 Zelzah Ave 818-366-4118 F/T 1 U

Hamlin Dental Group #1764018540 Reseda Blvd Ste 101 818-701-6667 P/T 3 (SP, PE, TA, RO)Homa Shahriari DDS, Inc #0027538632 Balboa Blvd 818-894-6161 F/T 1 (SP, PE) U

Lawrance Levine, DDS #0264018363 Reseda Blvd Ste 202 818-885-0536 F/T 1 U

Northridge Dental Office #00824618519 Devonshire St 818-831-9990 F/T 1 P/T 2 (AM, SP) U

Northridge Family Dtl Center #0192609514 Reseda Blvd Ste 6 818-775-1300 F/T 1 (FR, SP)Richard Rothstein, DDS #1061019145 Reseda Blvd 818-886-9920 F/T 1 P/T 1 (KO, SP, CH)Shanram Nouri Dental Corp #0180179068 Tampa Ave 818-885-5200 F/T 1 (PE, SP) U

Smilecare-Northridge #00396517017 Devonshire St 818-360-2216 F/T 1 P/T 7 (SP) U

NORWALKChan Lee, DDS #36400111780 Firestone Blvd 562-868-9897 F/T 1 (CH, SP, TA) U

Newport Dental #01314011481 Rosecrans Ave 562-863-3457 F/T 4 P/T 8 (SP) U

Norwalk Dental! #01559112052 Imperial Hwy Ste 101 562-863-4775 F/T 2 P/T 7Norwalk Family Dental #00320412319 Imperial Hwy 562-868-7955 F/T 1 (SP, HI) U

Norwalk Family Dentistry #00272015617 Studebaker Rd Ste 5 562-484-3936 F/T 1 (SP, TA) U


n How to enroll in KPIC’s Dental Insurance Plan

1) Complete the enrollment form on page 7. If you are already a Kaiser Permanente member, please include a copy of your Kaiser Permanente ID card. If you are not yet a Kaiser Permanente member, please include a copy of your Medical Enrollment Form (Form SF 2809). You must be a Federal member of Kaiser Permanente to enroll.

2) Sign the form to authorize automatic payment from your checking, savings or credit union account. Be sure to enclose a voided blank check or deposit form from this account. Call your bank to obtain the automatic deposit routing number and write the number on the payment authorization form.

3) Return the first month’s payment and enrollment materials by December 21, 2010, to:

KPIC Federal Employee Group Dental Insurance PlanWolfpack Insurance Services, Inc.P.O. Box 720Belmont, CA 94002-0720

4) If your payment and enrollment materials are received by KPIC’s Administrator by December 21, 2010, your effective date of coverage (including your eligible dependents) will be January 1, 2011.

n Monthly Rates for Calendar Year 2011:

One person ...................................................................... $29.03 Two persons..................................................................... $51.44 Three or more persons .................................................... $77.32

n Payment of Monthly Charges

The dental coverage described in this brochure will not become effective until KPIC or its Administrator receives the initial premium from the eligible Federal Employee. The due date for subsequent premiums is the 10th day of each month. The Insured agrees to pay subsequent premiums no later than 31 days following the premium due date, unless the Insured has given notice requesting termination of dental coverage under the Certificate in accordance with the Termination section of the Certificate. The Insured will be responsible for the payment of the pro rata premium for the time dental coverage under the Certificate was in force during the 31-day grace period.

n Billing

To ensure timely processing of your benefits and claim payments, it is necessary that premiums be paid during the month prior to the coverage month. There are two payment options.

You may choose to have your monthly premiums deducted from your checking, savings or credit union account on the 10th of each month prior to the coverage month (e.g., April dues will be deducted on March 10). Please complete the Automatic Payment Authorization form on page 8 of this brochure.

If you do not have a checking, savings or credit union account, you may submit payments via a personal check, money order, etc. When completing the enrollment form, write DIRECT PAY across the top of page 8, “Automatic Payment Authorization.” You will be sent monthly invoices to submit with your premium payments. Premiums must be paid by the 10th of each month prior to the coverage month.

32 5

Adjustments to denturesD5410 Adjust complete denture — maxillary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.00D5411 Adjust complete denture — mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.00D5421 Adjust partial denture — maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.00D5422 Adjust partial denture — mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.00

Repairs to complete denturesD5510 Repair broken complete denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.00D5520 Replace missing or broken teeth — complete denture (each tooth) . . . . . . . . . . . . . . . . . . . . . . . 25 .00

Repairs to partial denturesD5610 Repair resin denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.00D5620 Repair cast framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00D5630 Repair or replace broken clasp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.00D5640 Replace broken teeth — per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.00D5650 Add tooth to existing partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.00D5660 Add clasp to existing partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.00

Denture rebase proceduresD5710 Rebase complete maxillary denture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.00D5711 Rebase complete mandibular denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.00D5720 Rebase maxillary partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89.00D5721 Rebase mandibular partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.00

Denture reline proceduresD5730 Reline complete maxillary denture (chairside). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.00D5731 Reline complete mandibular denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.00D5740 Reline maxillary partial denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.00D5741 Reline mandibular partial denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47.00D5750 Reline complete maxillary denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 70.00D5751 Reline complete mandibular denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70.00D5760 Reline maxillary partial denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.00D5761 Reline mandibular partial denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.00

Interim prosthesisD5820 Interim partial denture (maxillary) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85.00D5821 Interim partial denture (mandibular) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85.00

Other removable prosthetic servicesD5850 Tissue conditioning, maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00D5851 Tissue conditioning, mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.00

D6200-D6999 IX. PROSTHODONTICS, FIXED – Procedures subject to 6 month waitingperiod(Each abutment and each pontic constitutes a unit in a fixed partial denture.)

Partial denture ponticsD6210 Pontic — cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171.00D6211 Pontic — cast predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138.00D6212 Pontic — cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168.00D6214 Pontic — titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171.00D6240 Pontic — porcelain fused to high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176.00D6241 Pontic — porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 155.00D6242 Pontic — porcelain fused to noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170.00D6250 Pontic — resin with high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176.00D6251 Pontic — resin with predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155.00D6252 Pontic — resin with noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170.00

Fixed partial denture retainers – inlays/onlaysD6545 Retainer — cast metal for resin bonded fixed prosthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.00D6602 Inlay — cast high noble metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.00D6603 Inlay — cast high noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D6604 Inlay — cast predominantly base metal, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.00D6605 Inlay — cast predominantly base metal, three or more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D6606 Inlay — cast noble metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.00D6607 Inlay — cast noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D6610 Onlay — cast high noble metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6611 Onlay — cast high noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6612 Onlay — cast predominantly base metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6613 Onlay — cast predominantly base metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6614 Onlay — cast noble metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6615 Onlay — cast noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00D6624 Inlay — titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D6634 Onlay — titanium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.00

Fixed partial denture retainers — crownsD6720 Crown — resin with high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00 D6721 Crown — resin with predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161.00D6722 Crown — resin with noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.00 D6750 Crown — porcelain fused to high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00D6751 Crown — porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161.00 D6752 Crown — porcelain fused to noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.00D6780 Crown — 3/4 cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00D6781 Crown — 3/4 cast predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00 D6782 Crown — 3/4 cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.00D6790 Crown — full cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180.00D6791 Crown — full cast predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.00D6792 Crown — full cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.00D6794 Crown — titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180.00

Other fixed partial denture servicesD6930 Recement fixed partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.00D6940 Stress breaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.00D6970 Cast post and core in addition to fixed partial denture retainer . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.00D6971 Cast post as part of fixed partial denture retainer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.00D6972 Prefabricated post and core in addition to fixed partial denture retainer . . . . . . . . . . . . . . . . . . . . 44.00D6973 Core buildup for retainer, including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.00D6980 Fixed partial denture repair, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00

D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY – Procedures subject to 6 month waiting periodExtractions (includes local anesthesia, suturing, if needed, and routine postoperative care)D7111 Extraction, coronal remnants — deciduous tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 20.00D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal). . . . . . . . . . . . . . . . 39.00

Surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative care)D7210 Surgical removal of erupted tooth requiring removal of bone and/or section of tooth . . . . . . . . . 74.00D7220 Removal of impacted tooth — soft tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.00D7230 Removal of impacted tooth — partially bony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117.00D7240 Removal of impacted tooth — completely bony, with unusual surgical complications . . . . . . . . . 134.00D7250 Surgical removal of residual tooth roots (cutting procedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78.00

Other surgical proceduresD7260 Oroantral fistula closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225.00D7261 Primary closure of a sinus perforation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225.00D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth . . . . . . . . . . 132.00D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98.00D7285 Biopsy of oral tissue — hard (bone, tooth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136.00D7286 Biopsy of oral tissue — soft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108.00

Alveoloplasty — surgical preparation of ridge for denturesD7310 Alveoloplasty in conjunction with extractions — per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . 59.00D7311 Alveoloplasty in conjunction with extractions — one to three teeth or tooth spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.00D7320 Alveoloplasty not in conjunction with extractions — per quadrant . . . . . . . . . . . . . . . . . . . . . . . . 96.00D7321 Alveoloplasty not in conjunction with extractions — one to three teeth or tooth spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58.00

VestibuloplastyD7340 Vestibuloplasty — ridge extension (secondary epithelialization) . . . . . . . . . . . . . . . . . . . . . . . . . . 82.00D7350 Vestibuloplasty — ridge extension (including soft tissue graft, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). . . . . . . . . 218.00

Surgical excision of soft tissue lesionsD7411 Excision of benign lesion greater than 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240.00D7465 Destruction of lesion(s) by physical or chemical method, by report . . . . . . . . . . . . . . . . . . . . . . . . 100.00

Surgical excision of intra-osseous lesionsD7440 Excision of malignant tumor — lesion diameter up to 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . 110.00D7441 Excision of malignant tumor — lesion diameter greater than 1.25 cm . . . . . . . . . . . . . . . . . . . . . 160.00D7450 Removal of benign odontogenic cyst or tumor — lesion diameter up to 1.25 cm . . . . . . . . . . . . . 131.00D7451 Removal of benign odontogenic cyst or tumor — lesion diameter greater than 1.25 cm . . . . . . . . . 273.00D7460 Removal of benign nonodontogenic cyst or tumor — lesion diameter up to 1.25 cm . . . . . . . . . . 128.00D7461 Removal of benign nonodontogenic cyst or tumor — lesion diameter greater than 1.25 cm . . . . . . . . 220.00

Excision of bone tissueD7471 Removal of lateral exostosis (maxilla or mandible) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 162.00D7472 Removal of torus palatinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162.00D7473 Removal of torus mandibularis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162.00D7485 Surgical reduction of osseous tuberosity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162.00D7490 Radical resection of maxilla or mandible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,000.00

Surgical incisionD7510 Incision and drainage of abscess — intraoral soft tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 .00D7520 Incision and drainage of abscess — extraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70.00D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue . . . . . . . . . . . . . . . 59.00D7540 Removal of reaction-producing foreign bodies, musculoskeletal system . . . . . . . . . . . . . . . . . . . . 60.00D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone . . . . . . . . . . . . . . . . . . . . . . . . . 85.00D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body. . . . . . . . . . . . . . . . . . . . . . . 237.00

Treatment of fractures — simpleD7610 Maxilla — open reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470.00D7620 Maxilla — closed reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 377.00D7630 Mandible — open reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929.00D7640 Mandible — closed reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 890.00D7650 Malar and/or zygomatic arch — open reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600.00D7660 Malar and/or zygomatic arch — closed reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200.00D7670 Alveolus — closed reduction, may include stabilization of teeth. . . . . . . . . . . . . . . . . . . . . . . . . . 190.00D7680 Facial bones — complicated reduction with fixation and multiple surgica approaches . . . . . . . . 1,000.00

Treatment of fractures — compoundD7710 Maxilla — open reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.00D7720 Maxilla — closed reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.00D7730 Mandible — open reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,000.00D7740 Mandible — closed reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 748.00D7750 Malar and/or zygomatic arch — open reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800.00D7760 Malar and/or zygomatic arch — closed reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200.00D7770 Alveolus — open reduction stabilization of teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300.00 D7780 Facial bones — complicated reduction with fixation and multiple surgical approaches . . . . . . . . 1,000.00

Reduction of dislocation and management of other temporomandibular joint dysfunctionsD7810 Open reduction of dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800.00D7820 Closed reduction of dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.00D7830 Manipulation under anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172.00

Repair of traumatic woundsD7910 Suture of recent small wounds up to 5 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200.00

Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure)D7911 Complicated suture — up to 5 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400.00D7912 Complicated suture — greater than 5 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600.00

Other repair proceduresD7960 Frenulectomy (not incidental to another procedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115.00D7970 Excision of hyperplastic tissue — per arch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.00D7971 Excision of pericoronal gingival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.00D7972 Surgical reduction of fibrous tuberosity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.00D7980 Sialolithotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233.00D7981 Excision of salivary gland, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,000.00D7982 Sialodochoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00D7983 Closure of salivary fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.00

D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICESUnclassified treatmentD9110 Palliative (emergency) treatment of dental pain — minor procedure. . . . . . . . . . . . . . . . . . . . . . . 41.00

AnesthesiaD9220 Deep sedation/general anesthesia — first 30 minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.00D9221 Deep sedation/general anesthesia — each additional 15 minutes . . . . . . . . . . . . . . . . . . . . . . . . 36.00

Professional visitsD9430 Office visit for observation (during regularly scheduled hours) — no other services performed . . . . . 24.00D9440 Office visit — after regularly scheduled hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49.00

DrugsD9610 Therapeutic drug injection, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.00

Miscellaneous servicesD9930 Treatment of complications (postsurgical) — unusual circumstances, by report . . . . . . . . . . . . . . 19.00D9951 Occlusal adjustment — limited . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.00

Note: This Appendix represents codes and nomenclature excerpted from the version of Current Dental Terminology (CDT) in effect at the date of this Contract or amendment was issued. CDT coding and nomenclature are the copyright of the American Dental Association, and have been accepted as the standard for data transmission purposes under federal Administrative Simplification regulations. For the purposes of this Appendix, Delta Dental’s administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the then current version of CDT whether or not a revised Appendix B is provided. Notes in italic type have been added by Delta Dental for clarification.

Code Description Allowance Code Description AllowancePaddison Dental Group #12190112501 Norwalk Blvd 562-929-0880 P/T 2 (SP, PE)Pioneer Dental Inc #01259014034 Pioneer Blvd 562-863-8779 P/T 1 (PE, SP)Rose Dental Implant Center #02929413041 Rosecrans Ave Ste 207 562-404-1614 P/T 1 (KO, SP) U

OCEANSIDEBright Now! Dental #0335834170 Oceanside Blvd Ste 183 760-936-0000 F/T 1 P/T 5 (SP) U

College Dental Group #007275467 College Blvd Ste 2 760-631-3060 F/T 2 P/T 1 (SP)Dentistry 2000 #0023213529 Cannon Rd Ste 2G 760-945-7000 F/T 1 (SP, PE)Emerald Dental #0295104645 Frazee Rd Ste A 760-722-0137 F/T 1 P/T 1 U

Quarry Creek Dental Group #0111443430 Marron Rd Ste 300 760-730-1303 P/T 1 U

Randall Segovia, DDS., Inc #0164723837 Plaza Dr Ste 805 760-630-6354 F/T 1FrSouth Oceanside Dental Group #0111532484 Vista Way Ste B 760-439-0334 P/T 2 (SP) U

ONTARIOBright Dental Care #0039692543 S Euclid Ave 909-933-5266 F/T 1 (SP, AR) U

Euclid Dental Center #0165852905 S Euclid Ave Ste D 909-391-4300 F/T 1 (PE, SP)Family Dentistry #000194628 W Holt Blvd Ste C 909-986-6424 F/T 1 (SP) U

HS Gill Archibald Ranch Dtl #0088523065 S Archibald Ave Ste B 909-923-3640 P/T 1 (SP, VI) U

Irene Justin, DDS #0265712413 S Grove Ave 909-947-9700 P/T 2 (SP, HI, AR)Jaswant Suthar, DDS #3672012242 S Mountain Ave 909-391-1549 F/T 1 (SP) U

Kyung Chung, DDS #357001941 W Mission Blvd Ste H 909-984-7883 F/T 1 (KO, SP)New Century Dental Care #0214441520 N Mountain Ave Ste 123 909-988-9690 F/T 1 P/T 1 (SP, CH, JA) U

Ontario Family Dentistry #022868528 N Fern Ave 909-460-9552 F/T 2 (SP, CH) U

Ontario Smiles #0244664190 E 4th St Ste C 909-532-8518 F/T 1 (SP)Ontario Village Dental #019519533 W Holt Blvd Ste B 909-988-1992 P/T 1 (SP)Prime Dental Office #0228691049 W Philadelphia St 909-391-2324 F/T 1 P/T 1 (HI, EI, SP)River Arch Dental Group #0146162920 S Archibald Ave Ste C 909-923-2273 P/T 1 (SP, VI) U

William Stanley, DDS #001601211 N Euclid Ave 909-983-9639 F/T 2 P/T 1 (SP)ORANGEAce Dental #0137672291 N Tustin St 714-282-2525 F/T 1 (SP, VI) U

Bright Dental Care #025940765 N Tustin St 714-771-7474 F/T 1Ca Dental Group of Orange #0086701502 E Collins Ave 714-288-8464 P/T 1 (SP, VI)Cecile N Licauco, DDS #0342828418 E Chapman Ave 714-984-2050 (SP, TA)Comfort Smile #1C53011920 E Katella Ave Ste J 714-997-4133 F/T 1 (SP, CH)

Newport Dental #0047151710 E Chapman Ave 714-538-2311 F/T 4 P/T 9 (CH, SP)OC Smile Factory #032185245 N Glassell St 714-532-5600 F/T 1 (SP)Orange Dental Group #033008235 S Tustin St 714-744-0044 P/T 1 (SP) U

Orange Dental Office #002804424 S Main St Ste H 714-639-1922 F/T 1 P/T 1 U

Orange Hill Dental #2824013138 E Chapman Ave 714-639-2703 F/T 1 (SP, PE) U

Preferred Dental Care #0043932022 W Chapman Ave 714-978-3333 F/T 1 P/T 2 (SP, CH, VI) U

Prime Dental Care #013980805 W La Veta Ave Ste 210 714-639-6666 P/T 1 (SP, AR, FR) U

Shiny Dental Practice #0117381916 N Tustin St 714-282-9966 F/T 1 (PE, SP) U

St Catherine Dental Center #001875235 E Katella Ave 714-633-3336 P/T 2 (SP, VI) U

Town & Country Dental #3678011111 Town & Country Rd # 33 714-285-0505 F/T 3 (CH, SP) U

Tustin Plaza Dental #2804011872 N Tustin St 714-637-8662 F/T 1 P/T 2 (JA, SP, VI)West Coast Dental #006975179 N Tustin St 714-288-1035 P/T 2 (SP, TA, HI) U

OXNARDAna Hernandez Carr, DDS #222901979 W 7th St 805-985-1159 F/T 1 (SP)Beach Cities Dental Group #0306761801 Solar Dr Ste 290 805-278-8887 F/T 1 U

Dental Care of Oxnard #1C36011350 W Gonzales Rd Fl 2 805-988-5888 P/T 1 (SP) U

Esthetic Smiles #3955011901 Solar Dr Ste 135 805-988-2250 F/T 1 (AR, FR, SP) U

Fremont Square Fmly Dentistry #002749712 N Ventura Rd 805-988-4540 F/T 1 (SP) U

Iraj Movahhedi, DDS #019926 4225 Saviers Rd Ste 9 805-982-8283 F/T 1 (SP)Island Plaza Dental Group #0028232500 Saviers Rd 805-486-4896 P/T 2 (SP) U

Jean Francisco Braza, DDS #0123481050 N Ventura Rd 805-981-8880 F/T 1 (SP, TA)Luz Cubillos, DDS #004719451 W Gonzales Rd Ste 160 805-988-3303 F/T 1 (FR, SP) U

Oxnard Dental Group #0165052379 N Oxford Blvd 805-278-9499 P/T 1Pacific Dental Group #0023252150 N Rose Ave 805-604-0449 P/T 1 (SP) U

Rose Dental Group #0181752731 S Rose Ave Ste 101 805-483-3658 P/T 2 (SP) U

PACOIMAKishore Shah, DDS #14840113279 Van Nuys Blvd 818-899-2505 F/T 1 P/T 1 (SP, TA)Pacoima Fmly Dental Center #0182589722 Laurel Canyon Blvd 818-897-1234 F/T 1 (SP, PE)Paradise Dental Group #03149410059 Lrl Cyn Blvd Ste A 818-896-0043 P/T 1 (SP) U

Urizar Dental Clinic #00209213215 Van Nuys Blvd 818-890-6442 P/T 1 (SP)Wilfrido Gedang, DMD #01357913564 Van Nuys Blvd 818-897-5771 F/T 1

PALM DESERTDesert Crossing Dental Group #2C370172333 Highway 111 Ste B 760-674-9666 P/T 1 (SP) U

Desert Dental Assoc #03310072210 Highway 111 Ste E-1 760-773-2111 P/T 1 U

Desert Gateway Dental Group #02288834460 Monterey Ave Ste 100 760-321-1259 F/T 1 P/T 1 (SP, AR) U

Palm Desert Dental Center #02459073733 Fred Waring Dr Ste 207 760-773-0052 F/T 1 P/T 1 (PE, SP) U

Parc Center Dental #02626077564 Cntry Club Dr Ste 350 760-772-7082 F/T 1 P/T 1Sunlife Dental Group #03185373211 Fred Waring Dr Ste 201 760-568-3368 F/T 1 (SP) U

PALM SPRINGSDesert Dental Group #1998011111 Tahquitz Cyn Way 210 760-327-1125 F/T 1 P/T 2 (SP)Palm Canyon Dental Office #029953180 E Palm Canyon Dr 760-322-1002 F/T 1PALMDALEAndre Kanarki, DDS #0009971543 E Palmdale Blvd Ste B 661-274-1866 F/T 1 (AM, FR, SP, TA)Bright Now Dental #02096839345 10th St W Ste B 661-274-8065 F/T 2 P/T 15 (SP)Gateway Dental Group #02673238209 47th St E Ste E 661-236-0046 F/T 1Hi-Desert Dental Center #0017322205 E Palmdale Blvd 661-273-1333 F/T 1 P/T 1 (RU, SP, PE) U

Oasis Dental Care #02587040008 10th St W Ste F 661-947-2727 F/T 1 (PE, SP)Premier Dental Care #1C08013005 E Palmdale Blvd Ste 22 661-273-5221 P/T 1 (AM, AR, SP) U

Sierra Commons Dental Grp #017650755 W Rancho Vista Blvd 661-265-7800 F/T 1 P/T 1 (SP) U

Smilecare-Palmdale #00150738745 Tierra Sub Ave Ste 150 661-272-9091 F/T 2 P/T 4 (SP) U

Thelma Buado, DDS #0210263025 E Avenue S Ste A14 661-265-7694 F/T 1 (SP, TA) U

PALOS VERDES PENINSULAPeninsula Dental Arts #3C3801550 Deep Valley Dr Ste 347 310-377-9575 P/T 2 (SP, PE)PANORAMA CITYDan Rosen/Sr Nourian DDS #3418018424 Van Nuys Blvd 818-893-4222 P/T 2 (SP, PE, HE) U

Dental Plus California #01344514415 Chase St 818-830-9050 P/T 3 (SP) U

Dental Wonderland #0168698761 Van Nuys Blvd 818-891-1600 F/T 1 P/T 2 (SP, AM, AR, FR) U

Dentalville #0219197864 Van Nuys Blvd 818-989-2400 F/T 3 P/T 1 (AM, RU, SP, TA) U

Erlinda Rosenthal, DMD #01722913760 Roscoe Blvd 818-893-9222 F/T 1 (SP, TA) U

Gary Karsh, DDS #3572018614 Van Nuys Blvd 818-895-1321 P/T 1 (RU, SP) U

Gentle Dental Center #3C480114526 Roscoe Blvd 818-893-7858 P/T 1 (RU, SP)Koo DDS., Inc #0130598215 Van Nuys Blvd Ste 220 818-782-8261 P/T 2 (CH, KO, SP)Latin Dental Group #0309548111 Van Nuys Blvd Ste 107 818-994-6080 F/T 1 (SP) U

Shimon Rabbani, DMD #01235014554 Nordhoff St 818-891-2345 F/T 1 (SP)Van Nuys Panorama Dental Ctr #0028038227 Van Nuys Blvd 818-989-3074 F/T 1 (AR, SP) U

PARAMOUNTDr Chebbi Dental Office #01864916260 Paramount Blvd Ste G 562-633-5070 F/T 1 P/T 1 (AR, FR, SP)Paramount Family Dental Ctr #3707018131 Rosecrans Ave Ste 101 562-634-2984 F/T 1 (SP, CH) U

West Coast Dental #35590114525 Lakewood Blvd Ste A 562-272-0000 P/T 2 (SP)PASADENAAlen Baktamian, DMD #3C2601301 S Fair Oaks Ave Ste 208 626-431-2654 P/T 1 (AM, PE, SP) U

Arakelyan Dental #001746720 N Lake Ave Ste 7 626-808-9797 P/T 1 (AM, RU) U

David Wyndhamsmith, DDS #3166011092 E Green St 626-795-9328 P/T 2 (KO, SP) U

Dental Plus/Leon Roisman DMD #038601310 S Lake Ave Lowr Level 626-795-6855 F/T 4 (SP) U

Fair Oaks Family Dental #028398929 N Orange Grove Blvd 626-449-3700 F/T 3 P/T 2Gentle Care Health Spa #022435247 N Lake Ave 626-405-2922 P/T 1 (AM, AR, SP) U

Green Street Dental #3593011175 E Green St 626-578-1687 F/T 1 U

Hastings Ranch Dental Group #017210255 N Rosemead Blvd 626-351-0195 P/T 1 U

Ibrahim Rabadi, DDS #0217782281 E Washington Blvd 626-794-2606 F/T 1 (AM, AR, TR, RU) U

Lakeview Dental #019231709 N Lake Ave 626-797-8900 P/T 1 U

Newport Dental Pasadena #01290881 N Lake Ave 626-440-0240 F/T 2 P/T 15 (SP, AM, PE, VI)Pasadena Dental Associates #2724011302 N Altadena Dr 626-797-6778 F/T 2 (AM, CA, SP)Pasadena Dental Center #004502766 N Lake Ave 626-808-1717 P/T 1Pasadena Family Dental Center #001902950 E Colorado Blvd Ste 201 626-431-2930 P/T 1 (SP) U

Rene & Tina Ghotanian, DDS #016419212 S El Molino Ave 626-792-7900 P/T 2Rose City Dental Arts #0188821855 E Colorado Blvd 626-440-0801 P/T 1 U

Shaun Malek, DDS #148701465 N Lake Ave 626-405-1445 F/T 1 (SP) U

Sinai Dental Practice #031178668 N Los Robles Ave 626-405-9090 F/T 1 U

Superb Dental Care #031651109 W California Blvd 626-844-7778 P/T 1 (SP, TA) U

Washington Dental Group #1C82012554 E Washington Blvd 626-296-0056 F/T 1 P/T 1 (SP) U

PERRISCrossing Dental Group #0228853150 Case Rd Bldg C 951-345-4386 P/T 2 (SP) U

Gentle Dental Perris #0329812560 N Perris Blvd Ste F1 951-657-6466 P/T 3Perris Family Dental Care #013535330 E 4th St 951-940-5855 P/T 1 (SP)PICO RIVERAAshokkumar Mehta, DDS #3206019514 Whittier Blvd 562-942-2345 P/T 1 (SP, FR, VI) U

Bright Smile Dental #0250678819 Whittier Blvd Ste 102 562-699-1000 F/T 1Cord Family Dental Care #0217008716 Cord Ave 562-949-2526 F/T 2 (SP, PE) U

Danny Muditajaya, DDS #3675019123 Slauson Ave 562-949-0177 F/T 4 (SP, TA) U

Dental Masters #0127458982 Washington Blvd 562-222-1551 F/T 1 P/T 1 (SP) U

Family Dentistry #0000134400 Rosemead Blvd Ste 2 562-695-5251 F/T 1 (HI, SP) U

Pico Rivera Family Dentistry #0292819401 Slauson Ave 562-949-9500 F/T 1 P/T 1Prime Care Dental #0238578803 Whittier Blvd Ste 200 562-463-6163 P/T 2 (KO, SP)Rivera Family Dental #1439019050 Whittier Blvd 562-942-8900 F/T 1 (AM, SP) U

PLACENTIACoastal Dental Care #0078791858 N Placentia Ave 714-577-9070 P/T 2 (SP, VI) U

Imperial Rose Fmly Dentistry #0292961061 E Imperial Hwy 714-577-7575 F/T 1 (KO, SP) U

Naomi and Anthony Wong DDS #004485415 W Chapman Ave 714-223-2021 P/T 2 (CH, SP)Placentia Family Dentistry #0160131525 N Placentia Ave Ste H 714-528-0089 F/T 1 (CH, SP, VI)Rose Linda Dental #0016741203 E Yorba Linda Blvd 714-528-2833 F/T 1 (GE, SP, PE) U

PLAYA DEL REYDel Dental Group #0129418035 W Manchester Ave Ste B 310-822-8118 P/T 1 (SP, PE) U

POMONABella Manchandia, DDS #001718551 E Holt Ave 909-622-8600 F/T 1 (HI)Donald Hodson, DDS #3480011956 Indian Hill Blvd 909-621-5848 F/T 1 (SP, PE)Family Dental Clinic #0054932280 S Garey Ave 909-364-0633 F/T 2 P/T 1 (SP)Gentle Dental Pomona #198201175 W La Verne Ave Ste A 909-593-5515 F/T 2 P/T 1 U

Grove Family Dental #0174763167 N Garey Ave 909-596-7700 P/T 3 (SP, HI, PE)Harpreet Gill, DDS #308201722 E Arrow Hwy 909-621-9177 P/T 1 (SP, TA) U

Kent Hung, DMD #011786520 E Foothill Blvd Ste B 909-624-1781 P/T 1 (CH, SP)Larissa Gushansky, DDS #017478887 E 2Nd St Ste D 909-865-8595 F/T 1 (SP, RU, CH)Pearl Dental Care #0111432407 Valley Blvd Ste C1 909-839-1004 P/T 1 (SP, HI) U

Pomona Dental Group #357101850 Indian Hill Blvd 909-626-3541 F/T 1 (KO, SP)Pomona Family Dental #032351956 N Garey Ave 909-629-9741 F/T 1Sahara Dental #0025092005 W Holt Ave 909-623-9590 F/T 1 P/T 1 (AR, SP) U

Zahra Dental Group #029158180 E Mission Blvd 909-623-5278 F/T 2 P/T 1 (PE, SP)POWAYA Poway Dental Group #00186713422 Pomerado Rd Ste 202 858-679-4949 P/T 1 U

Healthy Habit Dental #02423012620 Monte Vista Rd Ste D 858-485-8800 F/T 1 (SP) U

Pomerado Family Dental Grp #00962915706 Pomerado Rd Ste 201 858-674-5252 F/T 1 (SP)Poway Family Dental Group #00727313616 Poway Rd Ste 100 858-391-9300 P/T 2 (SP) U


D0100-D0999 DIAGNOSTICClinical oral evaluationsD0120 Periodic oral evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.00D0140 Limited oral evaluation — problem focused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.20D0150 Comprehensive oral evaluation — new or established patient . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.20D0160 Detailed and extensive oral evaluation, problem focused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.00 D0170 Reevaluation limited problem focused (established patient; not post operative visit). . . . . . . . . . 21.00 D0180 Comprehensive periodontal evaluation — new or established patient . . . . . . . . . . . . . . . . . . . . . 21.00

Radiographs/diagnostic imaging (including interpretation)D0210 Intraoral — complete series including bitewings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54.00D0220 Intraoral periapical — first film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.00D0230 Intraoral periapical — each additional film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.00D0240 Intraoral — occlusal film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.00D0250 Extraoral — first film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.00D0260 Extraoral — each additional film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.00D0270 Bitewing — single film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.00D0272 Bitewings — two films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.00D0274 Bitewings — four films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.00D0277 Vertical bitewings — 7 to 8 films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.00D0290 Posterior — anterior or lateral skull and facial bone survey film . . . . . . . . . . . . . . . . . . . . . . . . . . 19.00D0330 Panoramic film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.00D0340 Cephalometric film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.00

Oral pathology laboratoryD0472 Accession of tissue, gross exam, preparation and transmission of written report. . . . . . . . . . . . . 59.00D0473 Accession of tissue, gross & microscopic exam, preparation and transmission of written report. . . . . 59.00D0474 Accession of tissue, gross & micro exam, assessment of surgical margins for presence of disease, preparation and transmission of written report . . . . . . . . . . . . . . . . . . . . . . 59.00

D1000-D1999 II. PREVENTIVEDental prophylaxisD1110 Prophylaxis — adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.20D1120 Prophylaxis — child through age 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.60

Topical fluoride treatmentD1201 Topical application of fluoride (including prophylaxis) — child through age 13 . . . . . . . . . . . . . . . 38.40D1203 Topical application of fluoride (prophylaxis not included) — child through age 13 . . . . . . . . . . . . 13.20D1204 Topical application of fluoride (prophylaxis not included) — adult. . . . . . . . . . . . . . . . . . . . . . . . . 10.80D1205 Topical application of fluoride (including prophylaxis) — adult . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.60

Other preventive servicesD1351 Sealant— per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.00D1352 Preventive resin restoration — per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.00

Space maintenance (passive appliances) (including all adjustments within six months following installation).D1510 Space maintainer — fixed — unilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115.00D1515 Space maintainer — fixed — bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.00D1520 Space maintainer — removable — unilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143.00D1525 Space maintainer — removable — bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187.00

D2000-D2999 III. RESTORATIVE – Procedures subject to 6 month waiting periodAmalgam restorations (including polishing)D2140 Amalgam — one surface, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.00D2150 Amalgam — two surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.00D2160 Amalgam — three surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.00D2161 Amalgam — four or more surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58.00

Resin — based composite restorations — directD2330 Resin-based composite — one surface, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.00D2331 Resin-based composite — two surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.00D2332 Resin-based composite — three surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.00D2335 Resin-based composite — four or more surfaces or involving incisal angle (anterior) . . . . . . . . . . . 68.00D2390 Resin-based composite crown, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.00D2391 Resin-based composite — one surface, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47.00D2392 Resin-based composite — two surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64.00D2393 Resin-based composite — three surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00D2394 Resin-based composite — four or more surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00

Inlay/onlay restorationsD2510 Inlay — metallic — one surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99.00D2520 Inlay — metallic — two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.00D2530 Inlay — metallic — three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.00D2542 Onlay — metallic — two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.00D2543 Onlay — metallic — three surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.00D2544 Onlay — metallic — four or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.00D2650 Inlay — resin-based composite — one surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34.00D2651 Inlay — resin-based composite — two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00D2652 Inlay — resin-based composite — three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63.00

Crowns — single restoration onlyD2710 Crown — resin (indirect) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00D2712 Crown — 3/4 resin-based composite indirect) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00D2720 Crown — resin with high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182.00D2721 Crown — resin with predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.00D2722 Crown — resin with noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177.00D2740 Crown — porcelain/ceramic substrate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192.00D2750 Crown — porcelain fused to high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182.00D2751 Crown — porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.00D2752 Crown — porcelain fused to noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177.00D2780 Crown — 3/4 cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186.00D2781 Crown — 3/4 cast predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186.00D2782 Crown — 3/4 cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186.00D2790 Crown — full cast high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183.00D2791 Crown — full cast predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170.00D2792 Crown — full cast noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178.00D2794 Crown — titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183.00

Other restorative servicesD2910 Re-cement inlay, onlay, or partial coverage restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.00D2915 Re-cement cast or prefabricated post and core. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.00D2920 Re-cement crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.00D2930 Prefabricated stainless steel crown — primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65.00D2931 Prefabricated stainless steel crown — permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74.00

D2932 Prefabricated resin crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00D2933 Prefabricated stainless steel crown with resin window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.00D2934 Prefabricated esthetic coated stainless steel crown — primary tooth . . . . . . . . . . . . . . . . . . . . . 90.00D2950 Core buildup, including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.00D2951 Pin retention — per tooth, in addition to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.00D2952 Cast post and core in addition to crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.00D2954 Prefabricated post and core in addition to crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.00D2960 Labial veneer (resin laminate) — chairside. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116.00D2961 Labial veneer (resin laminate) — laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128.00D2962 Labial veneer (porcelain laminate) — laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161.00D2980 Crown repair, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00

D3000-D3999 ENDODONTICS – Procedures subject to 6 month waiting periodPulpotomyD3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to the dentinocemental junction and application of medicament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.00D3230 Pulpal therapy (resorbable filling) — anterior, primary tooth (excluding final restoration) . . . . . . 38.00D3240 Pulpal therapy (resorbable filling) — posterior, primary tooth (excluding final restoration). . . . . . 38.00

Procedures D3310 through D3450 include all test x-rays taken as part of the complete root canal procedure.

Endodontic therapy (including treatment plan, clinical procedures, and follow-up care).D3310 Anterior (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193.00D3320 Bicuspid (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227.00D3330 Molar (excluding final restoration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306.00D3346 Retreatment of previous root canal therapy — anterior . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 193.00D3347 Retreatment of previous root canal therapy — bicuspid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227.00D3348 Retreatment of previous root canal therapy — molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306.00D3351 Apexification/recalcification/pulpal — initial visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.00D3352 Apexification/recalcification/pulpal regeneration — interim medication replacement . . . . . . . . . . 56.00D3353 Apexification/recalcification — final visit (includes completed root canal therapy — apical closure/calcific repair of perforations, root resorption, etc .) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56.00

Apicoectomy/periradicular servicesD3410 Apicoectomy/periradicular surgery — anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240.00D3421 Apicoectomy/periradicular surgery — bicuspid (first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257.00D3425 Apicoectomy/periradicular surgery — molar (first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294.00D3426 Apicoectomy/periradicular surgery (each additional root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00D3430 Retrograde filling — per root. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57.00D3450 Root amputation — per root . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166.00

Other endodontic servicesD3920 Hemisection (including any root removal), not including root canal therapy . . . . . . . . . . . . . . . . . 121.00

D4000-D4999 V. PERIODONTICS – Procedures subject to 6 month waiting periodSurgical services (including usual postoperative services)D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or bounded teeth spaces per quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128.00D4211 Gingivectomy or gingivoplasty — one to three contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77.00D4240 Gingival flap procedure, including root planing — four or more contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.00D4241 Gingival flap procedure, including root planing — one to three contiguous teeth or bounded . . . teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95.00D4245 Apically positioned flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.00D4249 Clinical crown lengthening — hard tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96.00D4260 Osseous surgery (including flap entry and closure) — four or more contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342.00D4261 Osseous surgery (including flap entry and closure) — one to three contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205.00D4263 Bone replacement graft — first site in quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62.00D4264 Bone replacement graft — each additional site in quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47.00D4266 Guided tissue regeneration — resorbable barrier, per site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135.00D4267 Guided tissue regeneration — non-resorbable barrier, per site (includes membrane removal) . . . . 135.00D4270 Pedicle soft tissue graft procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192.00D4271 Free soft tissue graft procedure (including donor site urgery) . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 208.00D4273 Subepithelial connective tissue graft procedures, per tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233.00

Non-surgical periodontal serviceD4341 Periodontal scaling and root planing — four or more teeth per quadrant . . . . . . . . . . . . . . . . . . . 59.00D4342 Periodontal scaling and root planing — one to three teeth, per quadrant . . . . . . . . . . . .. . . . . . . 35.00D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis . . . . . . . . . . . . . . . . 36.00

Other periodontal servicesD4910 Periodontal maintenance (following active therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.00D4920 Unscheduled dressing change (by someone other than treating dentist) . . . . . . . . . . . . . . . . . . . . 36.00

D5000-D5999 IV. PROSTHODONTICS REMOVABLE – Procedures subject to 12 month waiting periodProcedures relating to dentures, partial dentures and relines include adjustments for a six month period following installation. Such procedures do not include specialized techniques involving precision dentures, personalizationor characterizations.

Complete dentures (including routine post-delivery care)D5110 Complete denture — maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240.00D5120 Complete denture — mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241.00D5130 Immediate denture — maxillary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240.00D5140 Immediate denture — mandibular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241.00

Partial dentures (including routine post-delivery care)D5211 Maxillary partial denture — resin base (including conventional clasps, rests and teeth) . . . . . . . 203.00D5212 Mandibular partial denture — resin base (including any conventional clasps, rests and teeth). . . . . . 212.00D5213 Maxillary partial denture — cast metal framework with resin denture bases (including conventional clasps, rests and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287.00D5214 Mandibular partial denture — cast metal framework with resin denture bases (including . . . . . conventional clasps, rests and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287.00D5225 Maxillary partial denture — flexible base (including any clasps, rests and teeth) . . . . . . . . . . . . 216.00D5226 Mandibular partial denture — flexible base (including any clasps, rests and teeth) . . . .. . . . . . . 216.00D5281 Removable unilateral partial denture — one piece cast metal (including clasps and teeth). . . . . 120.00

Code Description Allowance Code Description Allowance

KPIC Dental Insurance Plan 2011 Table of AllowancesThe benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under the Delta Dental program and is not to be interpreted as CDT-2011 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.

4 33Revisions to the Current Dental Terminology (CDT) Codes may not have been reflected in the above Table of Allowances. Please refer to your Certificate of Insurance for the updated Table of Allowances.

Yong Jun Park, DDS #02815412307 Poway Rd Ste B 858-668-3390 F/T 1 (SP, KO) U

RANCHO CUCAMONGAAnthony Kavorinos, DDS #05310110630 Town Center Dr Ste 131 909-987-6643 F/T 1 P/T 1 U

Bright Now! Dental #01484111561 Foothill Blvd Ste 104 909-483-7811 F/T 6 P/T 17 (SP) U

Dentistry By Dr Doshi & Assoc #0195007379 Milliken Ave Ste 110 909-945-3355 P/T 1 (SP) U

Dr Hattar Dental #0262439950 Foothill Blvd Ste T 909-980-4816 P/T 2 (AR, SP)Ghazal Dental Corporation #3C700110797 Foothill Blvd 909-581-0888 P/T 1Gina Barrameda, DMD #0185208351 Rochester Ave Ste 109 909-466-5352 P/T 2 (SP, TA) U

Grove Dental Group #0251798283 Grove Ave Ste 208 909-291-8625 F/T 1 (AM, RU, SP)Horizons Dentistry #0337939353 Fairway View Pl# 200 909-987-9933 F/T 1 P/T 1 (AR, SP) U

Jeffrey Lloyd, DDS #3591019310 Baseline Rd 909-989-1868 F/T 1 (JA, SP)Milliken Family Dentistry #0305299635 Milliken Ave 909-481-8990 F/T 1 (AR, SP) U

Monet Dental Group #02288612455 Victoria Grdns Ln 190 909-646-3057 P/T 2 (SP, TA) U

Oasis Dental #02953010801 Foothill Blvd Suite 10 909-941-2288 F/T 1 (TA, SP) U

Rancho Cucamonga Dental Care #39030110470 Foothill Blvd Ste 126 909-989-7888 F/T 1 (SP) U

Rania Refaat, DDS #1C74017388 Carnelian St Ste C 909-989-1758 F/T 1 (AR, SP) U

Renaissance Dental Care #0269329080 Milliken Ave Ste 100 909-987-0040 P/T 1Smilecare-Rancho Cucamonga #003966 9349 Foothill Blvd Ste B 909-980-6363 F/T 1 P/T 4 (SP)Star Dental Group #11770112729 Foothill Blvd Ste A 909-899-8757 F/T 3 (PE, SP)Upland Dental and Ortho #01293511328 Kenyon Way 909-945-5800 P/T 2 (VI, SP, Ch) U

Winery Estate Dental Group #0141157369 Day Creek Blvd # F-103 909-646-7902 P/T 2 (SP, VI) U

RANCHO MIRAGE Rancho Mirage Dental Group #02286272-027 Highway 111 #C 760-340-5155 P/T 2 (SP) U

RANCHO SANTA MARGARITAAppealing Dentistry #00840629839 Snta Mrgrita Pkwy 100 949-766-7687 P/T 1 (AR, HE, RU, SP) U

Elite Dentistry #01457022391 Antonio Pkwy Ste J200 949-888-8989 F/T 1 (CH, VI) U

Rancho Dental Group #3C650130592 Santa Margarita Pkwy 949-766-5740 P/T 1 (SP)Robert Murray, DDS #02608322032 El Paseo Ste 230 949-713-1606 P/T 1Santa Margarita Dtl Grp #01530722195 El Paseo Ste 260 949-459-9300 P/T 2 (PE, SP, TA)So Cal Smiles Dentistry #01383222195 El Paseo Ste 220 949-766-0006 P/T 1 (AR, RU, SP, TA)REDLANDSBeautiful Smile Dental Center #0305801895 Orange Tree Ln Ste 103 909-307-6453 F/T 1 (JA, SP)Bright Now Dental #0160121285 Alabama St Ste D 909-793-5777 F/T 5 P/T 7 (SP) U

Brookside Dental Associates #155201720 Brookside Ave Ste 100 909-798-7111 F/T 1 (SP) U

Drs Low & Li #301601229 Cajon St 909-792-9217 F/T 2 (CH, SP) U

Elite Dental Associates #028395245 Terracina Blvd Ste 207A 909-798-4111 F/T 1 U

Orange Plaza Dentistry #114501470 Orange St 909-793-4585 F/T 1 (CH, SP) U

Pavillion Smile Dental #0291462094 W Redlands Blvd Ste F 909-792-0500 F/T 1 (TA, SP)Redlands Dental Associates #012341860 W Redlands Blvd 909-793-5270 P/T 1 (RU, SP) U

Redlands Dental Group #005437 422 Orange St 909-792-7500 P/T 1 U

United Dental Group #018236434 Cajon St Ste 101 909-793-8793 F/T 2 P/T 5 (SP)REDONDO BEACHBarry Kashfian Dental Group #2700011917 S Catalina Ave # B 310-375-0787 P/T 1 (SP, PE)Bayside Dental Care #0214371884 1/2 S Pacific Coast Hwy 310-792-4627 F/T 1 P/T 1 (SP, HI)Dental Ctr of Redondo Beach #0027831959 Kingsdale Ave 310-921-3938 P/T 1 (AM, AR, PE, SP) U

Galleria Dental Care #1266012772 Artesia Blvd Ste 103 310-370-1586 F/T 2 (FR, IT, SP, PE) U

Redondo Beach Dental Arts #0057722731 Manhattan Beach Blvd 310-643-0880 F/T 1 P/T 1 (PE, SP)RESEDAAdult And Kids Dental #0299546915 Reseda Blvd Unit 6 818-881-6761 F/T 1Affinity Dental Group #0167376650 Reseda Blvd Ste 101B 818-705-7645 P/T 1 (PE, SP) U

Canby Dental #00166818440 Sherman Way 818-343-4024 P/T 1 (PE, SP) U

Citi Dental #0192596900 Reseda Blvd Ste C 818-705-0200 F/T 1 (PE, SP)City Dental Group #02870918511 Sherman Way 818-345-9800 F/T 1Columbus Dental Group #00403218305 Sherman Way # 7 818-996-9200 F/T 1 (SP) U

Esthetic Smile #02651419231 Victory Blvd Ste 216 818-344-4929 F/T 1Harvey Dlugatch, DDS #09290118909 Sherman Way Frnt 818-345-1343 F/T 1 (SP)Henide Arias, DDS #02718019231 Victory Blvd Ste 252 818-881-8940 P/T 1James Zarrinnegar, DDS #02311719231 Victory Blvd Ste 357 818-344-0177 P/T 2John Foroutan, DDS #00275418308 Sherman Way Ste 1 818-881-0404 F/T 1 (SP) U

Linda Kapgan, DDS #32540119301 Saticoy St Ste D 818-772-4222 P/T 1 (RU, SP) U

Reseda Dental Group #01398718437 Saticoy St Ste 1 818-344-8338 F/T 1 (AM, PE, SP, TA, TR)Reseda Dental Office #02459118554 Sherman Way 818-708-9919 F/T 1 (SP, RU, AM)Reseda Village Dental Studio #02911818700 Sherman Way Ste 116 818-757-7070 F/T 1 (SP, VI) U

San Fernando Valley Dtl Group #01925819231 Victory Blvd Ste 458 818-345-6477 P/T 1 (PE, TA)

Smile Masters Dental Center #00448017703 Vanowen St 818-609-0009 F/T 1 (SP, VI, PE, HI) U

RIALTOCare Family Dental #0129762836 W Rialto Ave Ste A 909-820-9454 F/T 1 (KO, SP)Dental Care Of Rialto Inc #1660011817 N Riverside Ave 909-879-1024 F/T 3 (CH, HI, SP)Designer Dentistry Rialto #0228021786 N Riverside Ave Ste 5 909-874-0323 F/T 4 P/T 3 (AR, PE, SP)Dr Ahuja and Dr Gill’s Dental #015811224 E Base Line Rd 909-874-4699 P/T 2 (SP, HI) U

Dr Ahujas Dental Office #0001311130 N Riverside Ave 909-873-0277 P/T 1 (SP) U

Family Dentistry #117501511 S Riverside Ave 909-820-2274 F/T 1 P/T 1 (SP)Family Dentistry #0228871734 N Riverside Ave Ste 3 909-875-1279 F/T 1 (CH, IN, SP)Paulette Newman, DDS #0113081733 N Riverside Ave 909-875-2548 F/T 1 U

Rialto Dental Group #0045141629 S Riverside Ave 909-421-2225 P/T 2 (SP) U

Samir Shah, DDS #022890469 W Base Line Rd 909-746-0444 F/T 1 (HI, SP)Tri Star Family Dental Center #000011106 N Eucalyptus Ave 909-875-1299 F/T 1 (SP, VI)RIVERSIDEAllan Etemadi, DDS #0001616071 Magnolia Ave 951-680-1777 F/T 2 (PE, SP)Anwar Nasser, DDS #0177766326 Mission Blvd Ste B 951-367-1666 F/T 1 (AR, SP)Arlington Dental #2C02013297 Arlington Ave Ste 101 951-683-6055 P/T 2 (SP)Arlington Family Dental #0147946160 Arlington Ave Ste D4 951-637-0013 F/T 1 (AM, SP)Arsen Sukiasyan, DDS #0176327000 Indiana Ave Ste 117 951-367-1345 P/T 1 (SP, RU, AM) U

CA Dental Grp of Riverside #0281583845 Pierce St Ste A 951-359-1900 F/T 1 P/T 1 (SP)Canyon Springs Dtl Grp #0155842878 Campus Pkwy Ste C-1 951-571-0011 F/T 1 P/T 1 (SP) U

Community Dental of Dr Chi #0035204595 La Sierra Ave 951-688-6000 P/T 1 (CH, KO, SP)Dental Assoc of Riverside #2675013487 Central Ave 951-369-1001 P/T 2 (SP)Dental Health Riverside #0271256339 Brockton Ave 951-369-3597 F/T 2Family Dentistry #0129514710 La Sierra Ave 951-324-8180 F/T 1 (SP)Gateway Dental Group #01433810286 Indiana Ave 951-359-5200 F/T 1 P/T 3 (SP, TA, VI) U

Gentle Dental- Riverside #00698310168 Indiana Ave 951-352-9747 F/T 2 P/T 2 U

Gentle Dental-Riverside #0069763630 Central Ave Ste 6 951-682-1720 F/T 2 P/T 2 (AR, SP) U

Grove Dental Group #0141418735 Trautwein Rd 951-776-1330 P/T 1 U

Hoang Nguyen, DDSInc #0106327120 Indiana Ave Ste B 951-276-2877 P/T 1 (SP, VI)Inner Brightness Dental #0316346165 Valley Springs Pkwy # E 951-214-6585 F/T 1

Julia Fundeanu, DDS., Inc #0106316860 Brockton Ave Ste 12 951-684-9917 F/T 1 (GE, SP, RO)La Sierra Family Dentistry #1523013410 La Sierra Ave Ste D 951-354-9550 F/T 1 (JA, KO, SP, GE, RO) U

Low Family Dentistry #0806016862 Palm Ave 951-683-5490 F/T 1 (SP)M J Savani, DDS #2073014080 Tyler St Ste D 951-359-0149 F/T 1 (SP, HI)Newport Dental #0007673724 La Sierra Ave Ste F1 951-688-2400 F/T 2 P/T 21 (SP)Newport Dental #0054653560 Arlington Ave 951-680-1200 F/T 5 P/T 19 (SP)Norma Vazquez, DDS #0324494060 Madison St 951-352-0500 F/T 1 (SP) U

Orangecrest Fmly Dtl Practice #02465119348 Van Buren Blvd Ste 117 951-789-9905 F/T 1 (PE, SP) U

Parissa Djafari, DDS #0127186900 Brockton Ave Ste 2 951-682-2245 F/T 1 P/T 1 (FR, PE, SP)Regal Dentistry #0256213950 Pierce St Ste L 951-688-0082 F/T 1 (SP)Reza Rajabi, DMD #0142437776 Limonite Ave 951-360-0696 F/T 1 P/T 1 (PE, SP, TA)Riverside Dental Office #0266121485 University Ave 951-784-4441 F/T 1Riverside Dentistry #1211011857 University Ave 951-781-3021 F/T 1 P/T 1 (SP, VI)Riverwalk Dental Spa #00776911695 Slate Ave Ste 200 951-353-0050 F/T 1 P/T 1 (SP) U

Smile Builder #021534473 E Alessandro Blvd # A 951-789-6886 P/T 1 (SP, CH) U

Smilecare-Riverside #00422110001 Indiana Ave 951-689-0701 F/T 3 P/T 4 (SP)Suraj Pal Sharma DDS., Inc #0117775515 Van Buren Blvd 951-352-5838 F/T 1 (SP, HI)Universal Care Dental #1C07014024 12th St 951-784-0636 F/T 7 P/T 3 (SP, TA, VI)West Coast Dental Group #0217033380 La Sierra Ave Ste 108 951-354-9999 P/T 1 U

ROSEMEADGlenrose Dental Group #0078938951 Glendon Way 626-288-7667 P/T 2 (CH, SP, TA)Min Lwin, DDS #0017058038 Garvey Ave Ste B 626-571-7000 P/T 2 (CA, CH, SP) U

Rosemead Family Dental Center #0162317556 Garvey Ave 626-573-2000 P/T 1 (SP, CH)Sethi Family Dental Center #0031332111 San Gabriel Blvd Ste I 626-280-4976 F/T 1 (SP) U

Smilecare-Rosemead #0035134100 Rosemead Blvd 626-575-1161 P/T 6 (SP)Steven Hou, DDS #0024962240 San Gabriel Blvd 626-288-8357 F/T 1 (CH, SP) U

ROWLAND HEIGHTSGrace Dental Care #02036417827 Colima Rd 626-965-7888 F/T 1 (KO, SP) U

Plaza Dental Group #26850118156 Colima Rd 626-965-0971 F/T 2 (SP, CH, KO) U

Smilecare-Puente Hills #00351118025 Gale Ave 626-965-2500 P/T 3 (SP)Steven Chiu, DDSInc #01259418906 Gale Ave Ste B 626-965-5618F/T 1 (CH)

Valley Dental Center #00541817595 Almahurst St Ste 101-2 626-965-7445 F/T 2 (SP, TA, VI) U

SAN BERNARDINOAhmed Naji, DDS #0153051799 N Waterman Ave Ste E 909-883-8282 P/T 1 (AR, SP)Alejandra Galindo-Magallanes #010256740 W 3Rd St 909-888-3688 P/T 1 (SP)Aloha Dental Practice #0182031799 N Waterman Ave Ste D 909-882-3745 P/T 1Arrowhead Family Dentistry #011183407 S E St 909-889-3300 F/T 2 P/T 7 (HI, SP)Brenda Evans-Louka, DDS #1935011848 Commerce Center East 909-382-0255 F/T 1 (AR, SP, FR) U

Citrus Dental #193801242 E Airport Dr Ste 100 909-890-0050 F/T 1 (SP) U

D Street Dental Group #2843011579-81 North “D” St 909-889-1977 F/T 1 (KO, SP)Dr Gill’s Family Dentistry #0292971584 W Base Line St Ste 103 909-885-3100 P/T 4 (SP)Hoang Nguyen, DDS #0110071918 Business Cntr Dr # 210 951-276-2877 P/T 1 (SP, VI)Hovsep Nargizyan, DDS #0109041655 N Mount Vernon Ave # B 909-885-8707 P/T 1 (SP, TA, AM, RU, VI, KO)Hub Plaza Dental Group #0127441047 Harriman Pl Ste B 909-796-6700 P/T 2 (GE, SP) U

Ian Shwartzman, DDS #0153062130 N Arrowhead Ave Ste 207 909-475-5565 P/T 1 (RU, SP)Inland Dental Center #1C7601599 Inland Center Dr Ste 116 909-384-1111 F/T 2 P/T 3 (KO, SP) U

Luis Vargas, DDS #000217965 S E St Ste N 909-885-6262 F/T 1 (CH, SP)Mgo Dental.Com #025852654 W 4th St # A 909-386-3650 P/T 2 (SP, TA, AR, FR) U

San Bernardino Dental Group #000129575 W 5th St 909-888-6581 F/T 2 P/T 2 (KO, SP)Sierra Gateway Dental Office #0133124168 N Sierra Way 909-886-8900 P/T 1 HI, VI U

Southland Dental Group #007367399 E Highland Ave Ste 120 909-881-0645 F/T 2 (SP)Sure Smile Dental Office #011723275 E 9Th St Ste L 909-381-5555 F/T 1 P/T 2 (SP, HI)Waterman Dental Center #3964011428 N Waterman Ave Ste A 909-889-1111 F/T 1 (SP) U

Wildwood Dental Group #0321243972 N Waterman Ave Ste 110 909-886-4864 F/T 1 P/T 1 (HI) U

SAN CLEMENTEAesthetic Dental Associates #0224681161 Puerta Del Sol 100 949-218-0433 F/T 1 (SP) U

Artistic Dentistry #012354439 N El Camino Real Ste E 949-366-1177 F/T 1 (PE, SP) U

Brighter Image Dental #0138441031 Avenida Pico Ste 203 949-361-6900 P/T 1 (SP, KO) U

San Clemente Dental Group #004795943 Avenida Pico Unit A 949-366-9555 P/T 2 (SP, TA, VI) U

San Clemente Dtl Associates #012873638 Camino De Los Mares C140 949-234-0500 F/T 2 (RU, RO, AR, SP, HE) U

Talega Dental Group #0090351151 Puerta Del Sol Ste A 949-369-8300 P/T 1 (PE, SP) U

SAN DIEGOAdvanced Dentistry #0233054320 Genesee Ave Ste 101 858-277-8100 P/T 1 (SP) U


• Prosthodontic appliances, including but not limited to fixed bridges and partial or complete dentures, will be replaced only after five years have elapsed following any prior provision of such appliances under any of KPIC’s dental insurance plans, except when KPIC determines that there is such extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory. Replacement will be made of a prosthodontic appliance not provided under a KPIC dental insurance plan if it is unsatisfactory and cannot be made satisfactory.

• KPIC group dental insurance plan will pay the listed allowance toward the dentist’s fee for a standard cast chrome or acrylic partial denture or a standard complete denture. (A “standard” complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials.)

• Implants (materials implanted into or on bone or soft tissue), or the removal of implants, are not benefits under this insurance plan. However, if implants are provided in connection with a covered prosthetic appliance, KPIC will make an allowance up to the listed allowance for a standard complete or partial denture toward the cost of implants and the prosthetic appliances. If KPIC makes an allowance toward the cost of such procedures, KPIC will not pay for any replacement placed within five years thereafter.

V. GENERAL LIMITATIONS — PROPHYLAXIS TREATMENTS AND OPTIONAL SERVICES

• Benefits under this insurance plan shall include only the first two prophylaxis treatments (cleanings) or single procedures which include prophylaxis, or combination thereof, provided to a patient in any calendar year while he or she is an eligible person under any KPIC dental insurance plan.

• If an eligible person selects a more expensive plan of treatment than is customarily provided, or specialized techniques rather than standard procedures, KPIC will pay the listed allowance for the lesser procedure, and the patient is responsible for the remainder of the dentist’s fee (examples: a crown where a silver filling would restore the tooth or a precision denture where a standard denture would suffice).

VI. SERVICES NOT COVERED (EXCLUSIONS) • Services for injuries or conditions which are

compensable under Workers’ Compensation or Employers’ Liability Laws; services which are provided to the eligible person by any federal or state government agency or are provided without cost to the eligible person by any municipality, county or other political subdivision, except as required by law.

• Services for restoring tooth structure lost from wear, for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion or for stabilizing the teeth. Such services include but are not limited to equilibration and periodontal splinting.

• Prosthodontic services or any single procedure started prior to the date the person became eligible for such services under the Policy.

• Prescribed or applied therapeutic drugs, premedication or analgesia.

• Experimental procedures.

• All hospital costs and any additional fees charged by the dentist for hospital treatment.

• Charges for anesthesia, other than general anesthesia administered by a licensed dentist in connection with covered oral surgery services.

• Extraoral grafts (grafting of tissues from outside the mouth to oral tissues) or implants (materials implanted into or on bone or soft tissue) or the removal of implants, except as provided under Limitations on Prosthodontic Benefits.

• Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joint or associated musculature, nerves and other tissues, unless covered by a rider to the Policy.

• Orthodontic services.

• Procedures not shown on the Table of Allowances.

• Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), unless covered by a rider to the Policy.

To determine exactly how much your out-of-pocket costs will be and what services will be covered, ask your dentist for a predetermination of benefits.

334

Aesthetic Dental Practice #0103854242 Camino Del Rio N Ste 24 619-640-3400 P/T 1 (PE, SP) U

Apple Dental #3C04011540 Fern St 619-236-9549 P/T 1 (CH, SP)Bernardo Dental Office #38560116466 Bernardo Ctr Dr # 185 858-676-1845 F/T 1 U

Bernardo Heights Dental Group #02024915731 Bernardo Hghts Pkw 101 858-674-6813 P/T 2Boulevard Dental Center #0316333531 El Cajon Blvd # A 619-584-8975 F/T 1Bright Care Dental Group #0259143078 University Ave 619-295-8891 F/T 1 (SP, VI, TA)Carmel Plaza Dental Center #01271111738 Carmel Mountain Rd 858-675-1180 F/T 1 (PE, SP, TA) U

Coast Dental Care #0106876585 El Cajon Blvd 619-265-0072 P/T 2 (SP, PE)Cosmetic And Family Dentistry #0141309636 Tierra Gnd St Ste 105 858-549-4511 F/T 1 (AM)Dream Smile #0138334501 Mission Bay Dr Ste 2E 858-270-6626 F/T 1 (PE, TR, SP)Extreme Smile Makeover #0120365927 Balboa Ave 858-751-5733 F/T 1 (SP, PE)Friars Mission Dental Group #0138705638 Mssn Ctr Rd Ste 104 619-293-7164 P/T 1 (SP)Gene Moore, DDS #231301286 Euclid Ave Ste 201 619-263-6683 F/T 1 (SP, CH)Gentle Dental North County #0102749855 Erma Rd Ste 108 858-578-9020 P/T 2Gentle Dental Sorrento Valley #00476711230 Sorrento Vly Rd # 130 858-458-9126 F/T 2 P/T 2Gentle Dentistry #0173064765 Carmel Mtn Rd #205 858-350-7400 P/T 1 (PE, GE, SP)Glenn E. Haldy DDS #1713013670 Clairemont Dr Ste 14 858-273-0540 F/T 1Hillcrest Family Dental Cr #0057353330 3Rd Ave Ste 400 619-291-8750 F/T 1 P/T 3 (TA, SP)Irresistible Smiles #0242394765 Carmel Mountain Rd 203 858-755-8993 F/T 1 (PE, SP) U

James F Misla, DDS #0340423737 Moraga Ave Ste A208 3 858-866-0656 F/T 1 (SP, TA) U

Jerome Bannister, DDS #2C65014370 Palm Ave Ste C 619-428-8682 F/T 1 P/T 1 (SP, TA)Mark Riedler, DDS #3779014167 Ohio St 619-281-6635 F/T 2 (SP, AR)Mesa Dental Group #0138197625 Mesa College Dr Ste 100 858-514-4290 F/T 1 (TA, PE, SP)Mission Bay Dental #3C69014295 Gesner St Ste 2B 619-275-2750 F/T 1 (Sp)Mission Dental Center #0325015995 Mission Gorge Rd Ste A 619-280-6500 P/T 1 (PE, SP)Naser Ostad, DDS #00282612330 Carmel Mtn Rd Ste C4 858-485-0555 F/T 1 (PE)Pacific Dental #0018959330 Mira Mesa Blvd Ste B 858-693-9070 F/T 1 P/T 1 (TA, VI) U

Pearl Cosmetic-Family Dntstry #01895513522 Sabre Spgs Pkwy # 201 858-513-1747 P/T 1 (PE) U

Rancho Dental Group #1895011442 University Ave 619-297-6104 F/T 1 (SP)Ray Derakshan, DMD #02170411134 Rch Carmel Dr Ste 103 858-485-1010 F/T 1 (PE) U

Richard Katnik, DDS #0081017319 Clairemont Mesa Blvd 858-569-9651 F/T 3 (SP, TA)San Diego Dental Arts #0303262168 Balboa Ave Ste 1 858-273-2800 F/T 1Serenity Dental Spa #02817212396 World Trade Dr Ste 208 858-673-1000 F/T 1 (SP, AR) U

Smile San Diego #0316312650 Cam Del Rio N Ste 102 619-298-0521 F/T 1 P/T 2 (SP, TA)Smilecare-Kearny Mesa #0025393820 Convoy St 858-569-1100 F/T 1 P/T 3 (SP)Smilecare-Mira Mesa #0024138997 Mira Mesa Blvd 858-536-5550 F/T 5 P/T 9 (SP)Smilecare-Mission Valley #0024111333 Camino Del Rio S Ste 20 619-260-4990 F/T 5 P/T 8 (SP)Smiles on The Bay #0112903737 Moraga Ave Ste B307 858-273-1631 P/T 1 (SP)Stephen Baral, DDS #252901306 Walnut Ave Ste 36 619-298-2942 F/T 1Sun Smiles Dentistry #01905011120 E Ocean Air Dr # B105 858-792-7823 P/T 1 (SP) U

Sunshine Dental Office #0C20019888 Carmel Mtn Rd Ste B 858-780-8870 F/T 1 (SP)Sunshine Dentistry #0031214230 30th St 619-282-1007 F/T 1 (SP, PE)Tierra Town Dental Center #03113510645 Tierrasanta Blvd Ste B 858-277-6080 F/T 1 (GE, IT, SP, VI) U

Tierrasanta Dental Group #01274210405 Tierrasanta Blvd 858-492-9300 F/T 1 P/T 1 (AR, SP, HI) U

Westview Dental Office #00713313350 Camino Del Sur Ste 6 858-484-9977 P/T 1 (SP)William Carlo, DMD #0221223333 5ThAve Ste 150 619-299-2550 F/T 1 (SP)SAN DIMASBouz Dental Corporation #3C6601639 E Foothill Blvd Ste A 909-599-2029 F/T 1 (AR, RU, SP)Family Dentistry #0116351437 W Arrow Hwy 909-305-6900 F/T 1 (AR) U

Plaza Dental Office #1999011120 Via Verde 909-599-2444 F/T 2 (FR, GE, SP) U

San Dimas Dental Office #011722923 W Arrow Hwy 909-592-5599 P/T 1 (SP) U

Sierra Dental Care #0299521301 W Arrow Hwy Ste 120 909-592-8338 F/T 1SAN FERNANDOAnatoly Vaisman, DDS #00938411273 Laurel Canyon Blvd 818-365-7191 F/T 1California Dental #0192182040 Glenoaks Blvd Ste F 818-361-3889 F/T 2 (AM, RU, SP)Heavenly Dental #020926321 N Maclay Ave Ste A 818-837-9744 P/T 2 (SP, PE, TA)Juan Falabella, DDS #0182921701 Truman St Ste B C 818-837-1660 F/T 1 (SP, TA) U

San Fernando Dental Care #3253011240 Truman St Ste 200 818-365-7107 P/T 1 (SP)San Fernando Dental Center #066801125 S Brand Blvd 818-365-6321 F/T 1 (TA, PE, SP, AM)Tooth Fairy Dental #002380556 S Brand Blvd 818-365-3004 F/T 1 (SP, TA)SAN GABRIELAnthony Cheing, DDS #0217755204 Rosemead Blvd 626-286-2111 F/T 1 (CA, CH, SP, VI, PE, TA, HI) U

Del Mar Family Dental #001455702 S Del Mar Ave Ste A 626-287-9781 P/T 1 (AR, SP) U

Dr. M Lwin #0014571739 S San Gabriel Blvd 626-288-5777 P/T 2 (CA, CH, SP)Hong Sun, DDS #0023786951 Rosemead Blvd 626-292-5865 F/T 1 (SP, CH) U

Las Tunas Family Dental #3719011107 E Las Tunas Dr 626-285-0031 P/T 1 (CH, SP) U

San Gabriel Dental Group #0239026909 Rosemead Blvd 626-286-8600 P/T 2 (CH, SP, CA) U

San Gabriel Family Dentistry #001807531 W Las Tunas Dr Ste B 626-281-1628 F/T 1 P/T 1 (SP, CH, VI) U

San Gabriel Valley Family Dtl #0133136503 Rosemead Blvd 626-286-2156 F/T 1 (CA, CH, FR, RU, SP, TA) U

Sun Dental #1766011720 S San Gabriel Blvd 626-288-9055 F/T 1 (CH, SP) U

Thomas Wu, DDS #0C35011103 S San Gabriel Blvd # A 626-286-7000 F/T 1 (CA, CH, TA, SP, HI, PE, AM) U

SAN JACINTOEsplanade Dental #0261672191 W Esplanade Ave # F106 951-487-2999 P/T 1 (VI, TA, SP) U

San Jacinto Dental Group #009003701 W Esplanade Ave Ste K L 951-654-3424 P/T 1San Jacinto Smiles #0248441821 S San Jacinto Ave D 951-654-7744 P/T 1 (SP) U

SAN JUAN CAPISTRANOCapistrano Dental Partnership #02893631878 Del Obispo St Ste 105 949-487-3273F/T 2 (AR, SP)Jeffrey Jacobson, DMD #01654532183 Camino Capistrano 949-489-1013 F/T 1 (SP) U

Mehrvarzi Mehrdokht Dtl Corp #0C970131952 Camino Cpstrno C14 C16 949-240-6888 F/T 1 (SP, TA)Ortega Dental Center #02817331726 Rancho Viejo Rd # B109 949-240-0250 P/T 1 U

RW Implant & Cosmetic Dentistry #03061831654 Rancho Viejo Rd # I- 1 949-240-4337 F/T 2 (SP) U

San Juan Dental Group #01358731897 Del Obispo St Ste 100 949-487-0284 F/T 1 (VI, SP)SAN LUIS OBISPODisbell Mansilla, DDS #0075741551 Bishop St Ste 420 805-547-7010 F/T 2 (AR, CH, KO, PE, SP, TA, VI)Mission Family Dental #0336694251 S Higuera St Ste 502 805-540-5251 F/T 1 (SP)Ricuccio Negom, DDS #032053735 Tank Farm Rd Ste 170 805-549-9000 P/T 1 (IT)SAN MARCOSAnna Durkin, DDS #0035321344 E Mission Rd Ste C 760-740-0070 F/T 1 (FR, RU, SP)Bright Now! Dental San Marcos #03358752 S Rancho Santa Fe Rd 760-936-0002 F/T 1 P/T 5 (SP)Grand Plaza Dental Group #024235137 S Las Posas Rd Ste 250 760-752-7000 F/T 1 (SP) U

San Elijo Dental #0280981691 Melrose Dr Ste 160 760-798-0828 P/T 1 (PE, SP) U

San Marcos Dental Group #009368709 Center Dr Ste 101 760-746-2045 P/T 2Smart Dental #031325960 W Sn Mrcos Blvd Ste 120 760-471-8800 P/T 1 (AR, SP, TA) U

Smiles of Lake San Marcos #0333911635 Lake San Marcos Dr # 10 760-591-3450 P/T 1 (SP) U

Smiles of San Marcos #023810630 Nordahl Rd Ste D 760-480-1750 F/T 1 (HI, TA) U

Sun Smile Dental Group #0137141582 W Sn Mrcos Blvd Ste 201 760-744-1300 F/T 1 (SP)Woodland Dental Group #019237979 Woodland Pkwy Ste 100 760-745-1100 P/T 1 (SP, PE) U

SAN PEDROHamid Cohen-Kheradyar, DDS #3C8301138 S Gaffey St 310-514-9100 F/T 1 (SP, PE)Milena Tasic, DDS #396501601 W 6Th St 310-831-1211 F/T 1 (GE) U

San Pedro Dental #019925697 S Gaffey St 310-548-1273 F/T 4 P/T 6 (SP) U

SANTA ANAAll Star Dental & Braces #026173940 N Grand Ave 714-541-9494 P/T 2 (PE, SP) U

Andrew Shieh, DDS #0120741028 W 1St St Ste E 714-542-5421 P/T 1 (CH, SP) U

Barba Dental Corp #0299572010 E 1St St Ste 250 714-558-6949 F/T 1Bay Dental #1605013620 S Bristol St Ste 307 714-540-2836 F/T 1 (SP, PE, VI) U

Bright Smile Dental #023242642 S Harbor Blvd 714-775-0202 F/T 1 (VI, SP, HI) U

Bristol Dental & Orthodontics #0309402502 S Bristol St 714-754-1888 F/T 1Dental 4 #013085102 E 4Th St Fl 2 714-558-1464 F/T 1 (SP)Family Dental #026080516 A West 17th Street 714-972-2506 F/T 1Friendly Smile Dental #0261641521 N Broadway 714-972-2801 F/T 1 (SP) U

Geeta Seth, DDS #0220991120 W Warner Ave Ste C 714-556-4740 F/T 1 (SP, HI) U

Iraj Ebrami, DDS #3771011125 E 17th St Ste E227 714-543-7770 P/T 1 (PE, SP)Kenneth Kim DDS A Prof Corp #0221062723 N Bristol St Ste D2 714-550-0006 P/T 1 (SP, KO) U

Louis Cohen, DDS #0C52011913 E 17th St Ste 113 714-547-9751 F/T 1 (SP)Nandini Murthy, DDS #0073332723 N Bristol St Ste D7 714-569-0021 P/T 1 (SP)Oasis Dental Santa Ana #027159408 W 4th St 714-836-9999 F/T 1 (SP, CH) U

Orange Coast Dental #0221401717 Old Tustin Ave 714-835-9188 F/T 1 (SP, PE)Pinnacle Dental Group #01287631 E Macarthur Cres Ste 109 714-549-1248 F/T 1 (PE, SP) U

Prakash Patel, DDS #0130872637 N Grand Ave 714-288-9980 P/T 1 (HI, SP) U

Santa Ana Dental #0214061631 N Bristol St Ste 100 714-567-9255 F/T 4 P/T 11 (SP) U

Shui Dental #0139931702 S Main St 714-796-9253 F/T 1 (SP, CH) U

Smilecare Dental Group #0134511718 N Main St 714-543-0600 P/T 4 (SP) U

Smilecare-South Coast #0039633500 S Bristol St Ste 100 714-957-6030 F/T 4 P/T 4 (SP) U

South Coast Dental Group #0130672231 S Bristol St 714-556-1001 F/T 2 (SP) U

South Coast Family Dental #0335542781 W Macarthur Blvd Ste N 714-556-7277 F/T 1 (PE, SP) U

Sweet Tooth Dental #030578301 1/2 N Main St 714-547-6600 P/T 2 (SP) U

United Dental Care #0147961710 E 17Th St Ste E 714-564-9000 P/T 1 (AR, SP)Universal Care Dental #1C02011400 N Main St 714-480-0434 F/T 3 P/T 4 (SP, VI) U

SANTA BARBARADennis Dierenfield, DDS #2C400116 W Mission St Ste A 805-569-2338 F/T 1 (SP)Gentle Dental Sta. Barbara #009433330 State St Ste A 805-963-1533 F/T 1 P/T 1 U

Sea Breeze Dental/Dr Zak #0C67015168 Hollister Ave Ste A 805-683-5300 F/T 1 P/T 2 (SP) U

SANTA CLARITABright Now Dental #02274926477-81 Golden Valley 661-253-1010 F/T 2 P/T 9 (SP) U

Dmitry G Aminov DMD #03348526781 Bouquest Cyn Rd 661-513-0655 P/T 1 (RU) U

Golden Triangle Dental #03414121700W Golden Triangle#201 661-259-5540 P/T 2 (AR, PE, SP)Valencia Dental Group #01641828134 Newhall Ranch Rd 661-607-0202 P/T 2 (SP) U

Zak Dental Care #13110126324 Bouquet Canyon Rd 661-253-4000 P/T 2 (RU, SP, PE, HI) U

SANTA FE SPRINGSSanta Fe Dental #00223910009 Orr and Day Rd 562-484-0808 F/T 1 (SP)SANTA MARIAFriendly Smiles Dental Group #0131622528 S Broadway Ste C 805-928-6776 F/T 2 (AM, CH, PE, SP, TA) U

SANTA MONICAAmerican Dental Center #0264911244 7th St Ste 204 310-394-3942 F/T 1 (PE, FR, GE, SP)American Family Dtl Office #0117052210 Santa Monica Blvd Ste B 310-264-5084 F/T 1 (SP, PE, HE, AR, GE, TA)Artistic Center For Dentistry #0318501531 6th St Apt 100 310-393-2300 F/T 1 (PE, TA) U

Douglas Oswell, DDS #0047013231 Pico Blvd 310-828-7429 F/T 3 P/T 1 (SP)Field And Field DDS #2004011807 Wilshire Blvd Ste A 310-453-5436 F/T 2 (SP) U

Santa Monica Dental #0C98011244 7th St Ste 101 310-393-0743 F/T 1 (SP)Super Dental Care #0130603200 Sta Mon Blvd Ste 204 310-453-8907 F/T 1 (SP, PE)Whiter & Brighter Dental #0120723201 Wilshire Blvd Ste 110 310-829-5181 P/T 2 (JA) U

Yosi Behroozan, DDS #0258712221 Lincoln Blvd Ste 200 310-399-1100 F/T 2Yvonne Goff, DDS #0328401304 15th St Ste 403 310-458-0800 P/T 1 U

SANTEEEdward Reidy, DDS #2195019280 Mast Blvd 619-449-8530 F/T 1Santee Cottonwood Dental #0218399715 Mission Gorge Rd 619-448-7444 P/T 2 (PE, SP, TA, RU)Santee Town Center Dental Grp #023560246 Town Center Pkwy 619-312-6006 P/T 2 (SP) U

Towne Center Dental Group #0064219862 Mission Gorge Rd Ste E 619-596-1600 P/T 2 (Sp)SAUGUSBouquet Smile Dental #01506128100 Bqt Cyn Rd Ste 200 661-263-6923 P/T 1 (VI) U


PREDICTABLE COSTS With KPIC’s group dental insurance plan you know exactly

how much KPIC will pay for a covered dental service. Just refer to the Table of Allowances on pages 4 and 5 of this brochure to see how much KPIC will pay for each covered dental service.

NO DEDUCTIBLE ON DIAGNOSTIC AND PREVENTIVE SERVICES Your calendar year deductible is $50 per person, up to a

maximum of $150 for the family. There is no deductible on diagnostic and preventive services. Your benefits cover a maximum of $1,000 of dental services for each covered enrollee per calendar year.

When you enroll in KPIC’s group dental insurance plan, you are enrolling for a period of one year. This does not apply if your employment is terminated.

WAITING PERIODS Some of the covered dental services listed in the Table

of Allowances are subject to a waiting period. This is the period of time that you and your covered dependents are required to have been continuously covered under KPIC’s group dental insurance plan before a specific dental service will be a covered benefit. Consult the Table of Allowances on pages 4 and 5 of this brochure for the specific dental services that are subject to a waiting period.

n BENEFITS KPIC’s group dental insurance plan covers the following

benefits when they are provided by a licensed dentist and when necessary and customary by the standards of generally accepted dental practice:

I. DIAGNOSTIC AND PREVENTIVE BENEFITS Diagnostic: oral examinations x-rays diagnostic casts biopsy/tissue examinations emergency palliative treatment specialist consultations

Preventive: prophylaxis treatments (cleanings) fluoride treatments space maintainers

Limitations on Diagnostic and Preventive Benefits • Benefits for oral examinations are limited to two

exams in any calendar year while the patient is covered under any KPIC dental insurance plan.

• Prophylaxis treatments are limited under General Limitations.

• Full mouth x-rays are covered only after five years have elapsed following any prior provision of full mouth x-rays under any KPIC dental insurance plan. Bitewing x-rays are covered on request by the dentist,

but not more than twice in a calendar year for children through 18, and once in a calendar year for adults, while the patient is an eligible person under any KPIC dental insurance plan.

II. BASIC BENEFITS Oral surgery: extractions and certain other surgical

procedures, including pre- and postoperative care

Restorative: amalgam, silicate or composite (resin) restorations (fillings) for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay)

Endodontic: treatment of the tooth pulp (root canal treatment)

Periodontic: treatment of gums and bones supporting the teeth

Sealants: protective coating for posterior molar teeth

Limitations on Basic Benefits Periodontal procedures which include prophylaxis are

limited under General Limitations.

Sealants are available for first molars for eligible persons through age 8 and for second molars for eligible persons through age 15. The benefit includes the application of sealants only to permanent first and second molars with no caries (decay), with no restorations and with the occlusal surface intact. The sealants benefit does not include the repair or replacement of a sealant on any tooth within three years of its application.

III. CROWNS, INLAYS, ONLAYS AND CAST RESTORATION BENEFITS

Crowns, inlays, onlays and cast restorations will be covered when teeth cannot be restored with amalgam, synthetic porcelain or plastic restorations.

Limitations on Crowns, Inlays, Onlays and Cast Restoration Benefits

Crowns, inlays, onlays and cast restorations will be replaced only after five years have elapsed following any prior provision under any KPIC dental insurance plan.

IV. PROSTHODONTIC BENEFITS Procedures for construction or repair of fixed bridges,

partial or complete dentures.

Limitations on Prosthodontic Benefits Prosthodontic treatment is subject to a six-month

period. See Table of Allowances for further reference.

2 35

SEAL BEACHGilbert Unatin, DDS #1447011900-A Saint Andrews Dr 562-430-1054 F/T 2 P/T 1Maged Zaky Nessim DDS., Inc #0000561058 Bolsa Ave 562-594-4885 P/T 1 (SP, AR)SHERMAN OAKSAnait Alabyan, DDS #0189114910 Van Nuys Blvd Ste 200 818-788-2121 F/T 1 (AM, RU, SP)Comfort Care Dental #0267585151 Hazeltine Ave 818-788-2023 F/T 2 (AM, SP, TA, AR)David Isaacs, DDS., Inc #0323294350 Woodman Ave 818-981-4508 F/T 1 (AF, HE, SP)Karen Arakelian, DDS #3C51014940 Van Nuys Blvd Ste 102 818-995-3377 F/T 1 (AM, RU, SP)KW Cheng & V Thay Inc #00760413732 Ventura Blvd 818-907-9533 F/T 1 P/T 1 (AM, CA, SP, VI) U

Sherman Oaks Cosmetic Dlt Grp #0295154955 Van Nuys Blvd Ste 520 818-990-4121 P/T 3 (AM, TA) U

SIMI VALLEYAnit Natt, DDS #0023791420 E Los Angeles Ave Ste D 805-581-1191 F/T 1 (SP) U

Boris Zak, DDS #3331014537 Alamo St Ste A 805-520-1100 P/T 1 U

Dental Care of Simi Valley #1761011687 Erringer Rd Ste 201 805-527-3534 F/T 1 (AM, PE, SP) U

Dental Center Of Simi Valley #0114004210 E Los Angeles Ave Ste F 805-579-0600 P/T 1 (AM, GE, PE, SP) U

First Street Dental Group #0126851197 E Los Angeles Ave Ste E 805-583-5700 F/T 1 (PE, SP, TA) U

Kostantinos Proussaefs, DDS #0225571445 E L.A. Ave Ste 300 805-526-8296 F/T 1 (GR, SP) U

Ralph Maiello DDS, Inc #253401495 E Los Angeles Ave 805-584-2228 F/T 2 P/T 2 (SP, VI)Simi Valley Dental Group #0063622410 Sycamore Dr Ste A 805-522-2600 F/T 1 P/T 1 (SP)Simi Valley Smiles #0291852650 Tapo Canyon Rd Ste 107 805-522-5516 P/T 2 (SP) U

Smile Planet Dental Group #0333372486 Erringer Rd 805-520-0100 P/T 2 (PE, SP) U

Ted Chaffee, DDS #0208582950 Sycamore Dr Ste 103 805-527-6400 F/T 1 (SP) U

SOLANA BEACHAblantis Dental #012881130 S Solana Hills Dr 858-259-8400 F/T 1 (SP) U

SOUTH EL MONTEAtlas Dental Care #0323373131 Santa Anita Ave Ste 201 626-444-2605 F/T 2 (PE, SP, VI)Dr Beri’s Dental Office #02274010496 Garvey Ave 626-442-5678 P/T 1 (HI, SP) U

Durfee Dental Office #0031352001 Santa Anita Ave Ste 204 626-443-3915 F/T 4 (CH, JA, SP, TA, VI)Garvey Dental Center #0213959328 Garvey Ave Ste A 626-350-0588 P/T 1 (CH, SP, VI) U

Tyler Dental Care #0189031928 Tyler Ave Ste D168 626-443-7922 F/T 1 (KO, SP)Universal Family Dental #01274710012 Garvey Ave Ste 11 626-433-1300 P/T 1 (SP, VI) U

Whelan Lok, DDS., Inc #01366010050 Garvey Ave Ste 105 626-444-4220 F/T 2 (CH, SP, CA) U

SOUTH GATEAdult & Childrens Dental Grp #1146014444 Tweedy Blvd 323-564-2444 F/T 25 P/T 1 (CH, PE, SP, TA) U

Castle Dental Center #0160114433 Tweedy Blvd 323-567-1227 F/T 5 P/T 4Dr Naziri Dental Clinic Inc #0127124186 Tweedy Blvd 323-569-7131 F/T 2 (PE, SP)Family Dental Center #0246505814 Imperial Hwy 562-869-2755 F/T 1 (HI, SP)Henry Shafajoo, DDS #0167622639 Santa Ana St 323-583-1481 P/T 1 U

Leticia J Jacobs, DDS #0232408200 Long Beach Blvd Ste E 323-581-0707 F/T 1 (SP) U

Magdy Tadros Family Dentistry #0246593173 Tweedy Blvd 323-564-4554 F/T 1 (AR, SP)Omid South Gate Dental #01351510530 Atlantic Ave 323-569-5000 P/T 1 (PE, SP) U

Perfect Smile #0131645863 Imperial Hwy Ste 2A 562-862-1345 F/T 1 P/T 1 (PE, SP) U

Samir Khayal, DDS #0251205841 Firestone Blvd Ste C 562-806-8611 F/T 1 (SP)West Coast Dental #2852014149 Tweedy Blvd Ste G 323-567-3333 F/T 1 P/T 2 (SP) U

SOUTH PASADENACaliforniasmile.Net #0052201506 Huntington Dr 626-799-2888 F/T 1 (SP) U

Healthy Smile Fmly Dentistry #0110271315 Fair Oaks Ave Ste 103 626-799-8068 P/T 2 (CH, SP) U

SPRING VALLEYCharlie Carmichael, DDS #3966018300 Prds Vly Rd Ste 122 619-479-9143 F/T 1 (TA)Smileburst Dentistry #1 #020927645 Sweetwater Rd 619-464-0426 P/T 3 (SP, TA, KO) U

STANTONJeffrey Chu, DDS., Inc #0032037025 Katella Ave 714-229-1234 P/T 1 (CA, CH, SP, TA, TH) U

Smile Academy #01748212793 Beach Blvd 714-903-9963 F/T 1 P/T 1 (HI, SP) U

Smile Family Dental #0165467757 Katella Ave Ste D 714-209-7702 F/T 1 (SP, CH) U

Stanton Dental #01259711001 Beach Blvd 714-891-6623 F/T 2 P/T 11 (SP) U

STUDIO CITYRoyal Dental Spa #01613811711 Moorpark St 818-505-1211 P/T 1 (AM, RU, SP) U

S C Dental Care #0054844366 Tujunga Ave 818-985-5462 P/T 2 (SP, PE)SUN CITYMc Call Dental Practice #02931228115 Bradley Rd Ste 3 951-723-1188 P/T 1Menifee Dental Group #00753729950 Haun Rd Ste 302 951-679-1667 P/T 1 (SP) U

Sun City Dentistry #02991427851 Bradley Rd Ste 155 951-679-0520 F/T 1 (PE)SUN VALLEYDrs Mishra & Kripalani #0110308381 Laurel Canyon Blvd 818-768-7800 F/T 1 P/T 1 (HI, SP)Family Dentistry #3799018805 Sunland Blvd 818-767-5243 F/T 1 P/T 1 (SP, TA) U

Fresh Smile Dental Center #0227718215 Sunland Blvd 818-252-7222 F/T 1 (PE, SP) U

Universal Care Dental #1280019375 San Fernando Rd Ste 602 818-504-9876 F/T 3 P/T 5 (CH, FR, IT, SP)SUNLANDSunland Dental Care #1341017902 Foothill Blvd 818-353-5520 P/T 2 (SP, AM, PE) U

Sunland Family Dentistry #0106448522 Foothill Blvd 818-352-8888 P/T 1 (RU, SP, AM) U

SYLMARKings Family Dental Group #02591214124 Foothill Blvd Ste 103 818-364-9444 F/T 1 P/T 1 (SP) U

Saint Mina Family Dental #02248812601 San Fernando Rd Ste H 818-364-1991 F/T 1 (AR, SP, FR) U

Sinai Dental Group #01328513060 Glenoaks Blvd Ste 105 818-899-1800 F/T 1 P/T 2 (PE, SP, TR, AM) U

TARZANAAngela Hoffman, DDS/. Inc #0171225620 Wilbur Ave Ste 316 818-345-7720 P/T 1 (RU, SP) U

Dental Plus Tarzana #03163019534 Ventura Blvd 818-881-2333 F/T 1 (FR, SP)Fara Salehi, DDS #35640118740 Ventura Blvd Ste 105 818-344-3357 F/T 1 (Pe, Ru, Sp)Shahin Shamsian, DDS #0047965620 Wilbur Ave Ste 309 818-881-1559 P/T 1 (SP, PE, TA) U

Theodore Stomel, DMD #01432919525 Ventura Blvd 818-708-7101 P/T 2 (RU, SP)TEHACHAPIValley Family Dentistry #2C890120300 W Valley Blvd Ste A 661-822-1134 F/T 1 P/T 1 U

TEMECULABright Now! Dental #01435630571 Temecula Pkwy Ste D 951-693-2079 F/T 1 P/T 9 (SP) U

Bright Now! Dental #02325939804 Winchester Rd Ste B 951-695-7100 P/T 11 (SP) U

Butterfield Dental #02459233321 Temecula Pkwy Ste 104 951-302-7508 P/T 1 (SP, CH, VI) U

Creekside Dental #02568541785 Nicole Ln # A3 951-699-3250 F/T 1 U

Dental Associates of Temecula #00422340820 Winchester Rd Ste 1500 951-296-6788 F/T 1 P/T 1 (SP) U

Friendly Dental Center #02614028314 Old Town Front St 951-676-8920 P/T 1 (SP, VI) U

Lynda Watanabe Dtl Corp #3C710127487 Ynez Rd 951-699-2144 P/T 1Margarita Esthetics Family #03379429049 Overland Dr Ste C 951-506-4900 F/T 1 U

Meadows Dental Group #01760631843 Rch Ca Rd Ste 300 951-676-2613 F/T 1 P/T 1 (SP) U

Pacific Dental Group #00642231754 Temecula Pkwy 951-694-5255 F/T 2 P/T 1Peter Bishay, DDSInc #02425028999 Old Twn Frnt St # 208 951-695-0310 P/T 1 (SP, FR, AR) U

Rubin Nichols, DDS #02422726475 Ynez Rd 951-296-9661 P/T 2 U

Smilecare-Temecula #00388740620 Winchester Rd Ste B 951-719-3182 F/T 2 P/T 1 (SP) U

Temecula Dental Group #25310141593 Winchester Rd Ste 211 951-296-3366 F/T 2 P/T 4 (SP, TA) U

TEMPLE CITYFriendly Dental Care #02235510455 Lower Azusa Rd 626-444-3744 F/T 1 (AM, CH, FR, PE, RU, SP)Happy Smile Dental #0299679600 Las Tunas Dr 626-286-9600 F/T 1 (CH, VI) U

THOUSAND OAKSAlex Bierman, DDS #029564223 E T. O. Blvd Ste 209 805-495-1061 F/T 1Dar Radfar, DDS #0155621459 E T. O. Blvd Ste B 805-497-9408 F/T 1 (SP, PE, FR)

East Oaks Dental Group #013796593 N Moorpark Rd Ste B 805-494-5255 F/T 1 P/T 1 (SP) U

Lombard Dental Group #244501245 Lombard St 805-495-2431 F/T 3 (AM, PE, SP, TA) U

Mojgan Hashemi, DDS #363301415 Rolling Oaks Dr Ste 120 805-449-9952 F/T 1 (PE, SP, VI)New Age Family Dental #0202841429 E T. O. Blvd Ste 101 805-230-9212 P/T 1 (PE, SP)Peter Sabolch, DDS #147501394 Lombard St 805-379-5222 F/T 1 (SP) U

Prism Dental Group #030675355 E Ave Arboles Ste A 805-241-5353 P/T 1 (HI) U

Royal Dental Spa #0130641459 Thousand Oaks Blvd # A 805-494-1831 F/T 1 (FR, PE, RU, SP)Skyline Dental #0242562875 E Thousand Oaks Blvd 805-496-2200 F/T 1 (PE, SP) U

Thousand Oaks Dental Group #0063631760 E Ave Arboles Ste A 805-493-5200 P/T 1 U

Westlake Smile Center #0320183665 E Thousand Oaks Blvd 805-496-3347 F/T 1 P/T 1 (HU, PE, SP) U

TIJUANADenticenter #322301Ave Circuito Bursatil9301202 619-482-0200 F/T 1 (SP)TOLUCA LAKEEsteban Bonilla, DDS #0C440110745 Riverside Dr Ste B 818-980-2887 F/T 1 (CH, SP) U

Tina Ghotanian, DDS #3C300110916 Riverside Dr 818-762-9966 F/T 2 (AM, SP)TORRANCEAll Care Dental #02995919019 Hawthorne Blvd 100 B 310-371-0113 P/T 1All Smiles Family Dntl Group #00137018506 Hawthorne Blvd 310-338-0444 F/T 1 P/T 2 (CH, PE, SP) U

Beautiful Smile Dental Center #0142521431 W Knox St Ste 800 310-320-1180 P/T 1 (SP, RU) U

Beaverly Grace Catalan, DMD #02167922759 Hawthorne Blvd 310-373-9522 F/T 1 (SP, TA) U

Blue Sky Dental Group #01266017311 Yukon Ave 310-324-3333 P/T 1 (PE, SP) U

Dental Assoc of Torrance #01880521229 Hawthorne Blvd Ste A 310-792-5600 F/T 1 P/T 1 (SP) U

Downtown Family Dental #0096062055 Torrance Blvd 310-320-0707 F/T 1 P/T 3 (SP, TA, HI, GE, RU) U

Dr Campbell Century Dental #0135381270 Sartori Ave 310-320-1471 P/T 2 (KO, SP)E Dental #03083724422 Hawthorne Blvd Ste A 310-378-2400 P/T 1 (KO, SP, TA) U

Joshua C H Chiu DDS., Inc #00181021320 Hawthorne Blvd Ste 212 310-543-1003 F/T 1 (CH, JA) U

Redondo Beach Dental Clinic #0214962130 Redondo Beach Blvd 310-768-8281 F/T 1 (SP, CA, CH) U

Smilecare-Torrance #003954923 W Carson St 310-533-1300 F/T 1 P/T 7 (SP) U

Torrance Dental Arts #0C870123326 Hawthorne Blvd Ste 190 310-378-8209 P/T 2 (SP, TA) U

Torrance Dental Associates #34730117305 Crenshaw Blvd 310-327-4166 F/T 2 (PE, SP, TA) U

Torrance Dental Center #01120021150 Hawthorne Blvd Ste 101 310-371-0777 F/T 1 P/T 1 (SP, PE, TA) U

Universal Care Dental #1279011001 W Carson St Ste E 310-618-1522 F/T 3 P/T 5 (CH, FR, IT, SP) U

Village Family Dental #2C42011235 Sepulveda Blvd 310-530-9656 F/T 1 P/T 1 (GR, VI, SP) U

West Coast Dental #3560011730 Sepulveda Blvd Ste 1 310-325-8888 P/T 1 (CH, SP) U

William G Zakaria, DDS #0124434350 Redondo Beach Blvd 310-370-2966 F/T 1 (AR)TUSTINA A Family Dental Group #00282718102 Irvine Blvd Ste 205 714-731-5656 F/T 2 P/T 1 (SP, HI, PE, VI, TA) U

Amit Shah, DDS #01153017602 17th St Ste 105 714-544-7511 P/T 1 (SP) U

Bella Dental Group #01994714122 Red Hill Ave 714-544-8338 F/T 1 (SP, AR, PE) U

Calvin Mclemore III, DDS #03265517482 Irvine Blvd Ste B 714-508-0995 P/T 1Elmer Yoshida, DDS #017217137 W 1St St Ste B2 714-730-9900 F/T 1 (JA, SP)Heba Guirguis, DDS #02991614151 Newport Ave Ste 100 714-505-1641 F/T 1 (SP) U

Kay Kim Dental #01583813132 Newport Ave Ste 220 714-505-2010 F/T 1 (KO) U

Nadia Rezaiamiri, DDS #00018813372 Newport Ave Ste F 714-665-0898 F/T 1 P/T 1Simona Kiss, DDS #01493918102 Irvine Blvd Ste 201 714-730-9656 F/T 1 (SP, RO, HU) U

Smile Dental Care #03315014001 Newport Ave Ste C 714-508-8500 F/T 1 (SP, VI) U

Southland Dental Arts #00438513771 Newport Ave Ste 11 714-838-3230 F/T 1 P/T 1 (SP, VI) U

Tustin Dental Care #01165112575 Newport Ave Ste B 714-731-6100 P/T 1 (AR, SP) U

Tustin Dental Office #1C620113721 Newport Ave Ste 1 714-368-1400 P/T 3 (SP) U

Tustin Smile Care #03331212791 Newport Ave 3200 714-665-0005 F/T 2 (HI, SP) U

UPLANDAlta Dental Care #021409 1113 Alta Ave Ste 205 909-985-6116 F/T 1 (SP) U

Crossroads Dental Group #0137971875 N Campus Ave Ste C 909-985-2302 P/T 2 (SP) U

Daniel Duroseau, DDS., Inc #033181930 W Foothill Blvd Ste D 909-608-2390 F/T 1 (FR, SP)Danny Lee, DMD #0327141049 W Foothill Blvd 909-985-1966F/T 1 P/T 1 (KO, SP) U

Douglas Johnson, DDS #017301980 E Foothill Blvd Ste 104 909-981-3341 F/T 1 (SP) U

Eric Chiang, DDS #0002321273 W 7th St 909-920-9543 F/T 1 (CH, SP) U

Magnolia Town Dental #029966258 E 9th St 909-946-3433 F/T 1 (GE, SP, FR) U

Steven Chiu, DDS., Inc #0334351183 E Foothill Blvd Ste 150 626-965-5618 P/T 1 (CH) U

Upland Dental Aesthetics #030554121 W Foothill Blvd Ste E 909-982-9800 F/T 1 (SP) U

Upland Smiles #029561270 E 7th St Ste 2C 909-982-8501 F/T 1 (SP) U

Yuen Siang Hung, DDS #3673011268 W Foothill Blvd 909-981-4111 P/T 1 (SP) U

VALENCIABaywood Dental Group #01235224121 Baywood Ln Ste A 661-291-1200 F/T 2 P/T 1 (Sp) U


36 1

ABOUT KPIC’S DENTAL INSURANCE PLAN If you’re concerned about the cost of dental treatment for you

and your family, you should know about KPIC’s group dental insurance plan. With a low monthly premium, KPIC’s group dental insurance plan allows you to budget for your annual dental costs. You can do this because KPIC’s dental insurance plan contains a Table of Allowances listing the specific dollar amount KPIC will pay for each covered dental service. Since you receive in advance the complete Table of Allowances for the plan, you’ll know exactly how much of your treatment will be covered. Because dental fees do vary by dentist, it may be to your advantage to compare your dentist's fees prior to making an appointment.

WHO CAN JOIN As a Federal employee or a Federal retiree enrolled in Kaiser

Permanente’s traditional HMO Plan, you and your eligible dependents are eligible for coverage under KPIC’s group dental insurance plan. Your eligible dependents include your lawful spouse and unmarried children under 26 years old, including stepchildren and children placed with you for adoption or foster care. An unmarried child 26 years of age or older may continue to be eligible as a dependent if incapable of self-support because of physical handicap or mental retardation that commenced prior to age 26, provided that the person is legally residing with and dependent upon the eligible member, and Delta Dental receives notice of the disability.

FREE CHOICE OF DENTISTS Many dental plans restrict your choice of dentists to one

from a limited network. But with KPIC’s group dental insurance plan, you may go to any licensed dentist. You and your covered dependents may even choose to go to different dentists. To use KPIC’s group dental insurance plan, simply make an appointment with the dentist of your choice. When seeing a participating dentist, be sure to give the dental office your Kaiser Federal group number and social security number.

SPECIAL ADVANTAGES FROM DELTA DENTISTS KPIC’s group dental insurance plan is administered by Delta

Dental of California, and you get special advantages when you go to one of the more than 30,000 Delta Dental dentist locations in California. These participating dentists have agreed to handle all your claims paperwork and to charge you no more than the fees negotiated by Delta Dental. As KPIC’s administrator, Delta Dental reimburses these dentists directly, so you are responsible only for the amount of the charge that exceeds the covered amount shown in the Table of Allowances. If you go to a non-participating dentist (a dentist not participating with Delta Dental), you are responsible for the entire charge and must submit a claim to Delta Dental for reimbursement. Delta Dental will reimburse you directly for the amount shown in the Table of Allowances. Since approximately 93 percent of California’s dentists are Delta Dental dentists, your current dentist is probably already participating. Ask your dentist if he or she is a Delta Dental dentist.

One of your non-FEHB Dental plan options is a dental insurance plan underwritten by KPIC, and administered by Delta Dental of California.

KPIC’s group dental insurance plan uses a Table of Allowances and allows you the freedom to see any licensed dentist of your choice. The Table of Allowances lists the dollar amount KPIC will pay for each covered dental service. A copy of the Table of Allowances is shown on pages 4 and 5 of this brochure.

The monthly premiums for 2011 are listed below:

Monthly KPIC Premiums* Dental Insurance Plan Self Only $29.03 Self & One Party $51.44 Self & Two or More $77.32


NOTE: This is only a brief description of your coverage. A certificate of insurance and schedule of coverage setting forth the terms and conditions of your coverage will be sent to you after you enroll. The dental coverage described in this section of the brochure is underwritten by Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP).

These benefits are neither offered nor guaranteed under contract with the FEHB Program.

KPIC DENTAL INSURANCE PLANC Squared Dentistry #02480828212 K Johnson Pkwy Ste 180 661-702-0940 F/T 1 (CH, PE)Canyon Dental Group #01566628237 Newhall Ranch Rd 661-257-4242 P/T 1 (SP) U

Daniel Liberman, DDS #01724423501 Cinema Dr Ste 112 661-290-3355 F/T 1 (RU, SP, TA) U

David Abri, DDS #02316623333 Cinema Dr Ste 190 661-254-9494 P/T 1 U

George Koutsoukos, DDS #03072524155 Magic Mountain Pkwy 661-222-7724 F/T 1 (GR, SP) U

Nilda Woolard, DMD #00354223369 Lyons Ave 661-259-7702 F/T 1 (SP) U

Raymond Lotuaco, DDS #01954823501 Cinema Dr Ste 207 661-753-9456 F/T 1 (SP, TA) U

Valencia Dental Arts #00801727420 Tourney Rd Ste 230 661-799-9989 F/T 1 (SP) U

Valencia Dental Care #12170123838 Valencia Blvd Ste 301 661-291-1412 P/T 2 (SP, KO) U

Valencia Dental Group #00766324218 Valencia Blvd 661-288-0288 P/T 1 (SP)Valencia Dental Group #00766426938 Old Road Ste P 661-799-0886 F/T 1 P/T 1 (SP)Vista Village Dental Group #00021525864 Tournament Rd Ste F 661-259-5001 P/T 1 (SP) U

VALLEY VILLAGEAllen Zebrack, DDS #01358412840 Riverside Dr Ste 406 818-763-9701 F/T 1 (SP)Laurel Chandler Dental #3053014717 Laurel Cyn Blvd Ste 200 818-508-2250 F/T 1 P/T 1 (SP, TA) U

Samuel Hunanian, DDS #0217455953 Laurel Canyon Blvd # B 818-508-7200 F/T 1 (RU, AM)VAN NUYSAffordable Gentle Dental #0072766600-A Van Nuys Blvd 818-782-5020 F/T 1 P/T 1 (CH, SP) U

Family Dentistry 2 #02249015355 Sherman Way Ste K 818-997-7797 P/T 1 (SP) U

Global Dental Practice #02178214434 Hamlin St Ste 2 818-781-5180 F/T 1 (SP)Gohar Hovsepyan, DDS #00942915333 Sherman Way Ste M 818-909-0200 F/T 1 (AM, RU, SP) U

Golden Care Dentistry #0305826330 B Van Nuys Blvd 818-785-9944 P/T 1 (PE, SP)Hamlin Dental Group #00280114401 Hamlin St Ste D 818-782-6919 F/T 1 P/T 2 (AR, TA, AM, PE, SP)Joseph Hakimi, DDS #0195526624 Van Nuys Blvd 818-909-9291 F/T 1 (PE, SP) U

Lourdes Alejandro, DDS #02427916221 Victory Blvd 818-781-2081 F/T 1 (TA, SP)Lourdes Aquino, DDS #01887914435 Sherman Way Ste 107 818-785-7498 F/T 1 (SP, TA) U

Maclay Bromont Family Dtl Grp #02274114435 Hamlin St Ste 104 818-781-0004 P/T 1 (SP, RU) U

Mc Dental #02104514306 Victory Blvd 818-786-6000 P/T 1 (SP, TA) U

Mehrzad Firouzbakht, DDS #02511914100 Victory Blvd 818-908-9199 F/T 1 U

Plaza Dental Clinic #0063987028 1/2 Van Nuys Blvd 818-780-8555 F/T 1 (SP, PE) U

Ricardo And Maria Pellegrini #02524714435 Hamlin St Ste 210 818-908-4090 F/T 2 (SP, IT)

Sherman Way Dental Group #1C80017120 Hayvenhurst Ave Ste 205 818-988-1642 F/T 1 (AM, AR)Sinai Dental Group #01278114550 Haynes St Ste 101 818-780-7555 F/T 1 P/T 4 (PE, SP) U

Sinai Dental Group #02386614523 Sherman Way 818-787-7300 F/T 1 P/T 1 (PE, SP) U

Smilecare-Valley #00400015643 Sherman Way Ste 300 818-786-2209 F/T 2 P/T 7 (SP) U

The Dental Care Center #3946017068 Sepulveda Blvd 818-781-1533 P/T 1 (SP, TA)Universal Care Dental #12770114600 Sherman Way Ste 100 818-756-6950 F/T 7 P/T 5 (SP, TA) U

Valley Dental Center #01259216440 Vanowen St 818-785-5445 P/T 2 (SP, AM, AR, VI, FR)West Coast Dtl Gp of Van Nuys #01387513716 Sherman Way 818-988-2020 P/T 2 (PE, TA, SP) U

VENICECastle Dental Center #0159521440 Lincoln Blvd 310-399-9900 F/T 4 P/T 5VENTURAAmerident Group #2C52016555 Telephone Rd Ste 8 805-642-2790 F/T 2 U

Main Street Dental Group #0164444360 E Main St Ste C 805-644-6110 P/T 2 (SP)Mission Dental Group #2C970126 S Garden St Ste I 805-648-1090 P/T 1 (SP) U

Pacific View Dental Group #0156053585 Telegraph Rd Ste C 805-676-1611 P/T 1 (FR, SP, PE, GR) U

The Delicate Art of Dentistry #0216831437 S Victoria Ave Ste C 805-644-9000 F/T 1 (RU, SP) U

Ventura Dental Group #199601001 Partridge Dr Ste 210 805-644-9501 P/T 2 (SP) U

Woodside Dental Care #00410910883 Telegraph Rd 805-647-1322 F/T 2 P/T 1VICTORVILLEDesert Dental Group #01990012640 Hesperia Rd Ste A 760-241-3336 F/T 6 P/T 1 (AR, TA) U

Desert Sky Dental Group #02105215667 Roy Rodgers Dr #101 760-843-5824 P/T 2 (SP)Desert Valley Dental Group #39090113622 Bear Valley Rd Ste 10 760-245-2010 F/T 1 P/T 1 (SP) U

Dr Hattar Dental #02989715366 Eleventh St Ste F 760-243-3595 P/T 1Procare Dental #03250212602 Amargosa Rd Ste D 760-951-9997 P/T 2 (SP, TA) U

Roy Soriano DDS & Assoc #02263915165 Seventh St Ste I 760-245-7704 F/T 1 (SP, TA)S M Bhatt, DDS #30640114495 Seventh St Ste A 760-245-7800 F/T 3 P/T 6 (HI, RU, SP)Victor Valley Dental Group #02608814689 Valley Ctr Dr Ste E101 760-245-0151 P/T 2 U

Viewpoint Dental Associates #00871315366 Eleventh St Ste G 760-245-8616 F/T 1 P/T 2 (SP, AR, RU) U

VISTACrossing Dental #0140803211 Business Park Dr Ste A 760-598-8881 F/T 1 (SP) U

Gerald Moore, DDS #002708610 S Melrose Dr 760-941-9000 P/T 1 (SP)La Jolla Townsite Fmly Dtl #029747706 Townsite Dr 760-724-4392 P/T 1 U

Melrose Square Dental Group #0138721680 S Melrose Dr Ste 108 760-727-6800 P/T 1

North County Dental Care #0234331000 E Vista Way 760-940-4266 F/T 2 (SP) U

Pearl Dental Family Practice #025817771 E Vista Way Ste 101 760-560-0600 F/T 1 (AR, SP)Smilecare-Vista #0031041010 E Vista Way Ste A B 760-940-8811 F/T 1 P/T 8 (SP)Vista Dental Group #006693435 B South Melrose Drive 760-758-7580 P/T 1Vista Family Dental Center #026702985 S Santa Fe Ave 760-940-8410 F/T 1 P/T 2 (SP) U

Vista Village Fmly Dentistry #032370950 Civic Center Dr Ste B 760-208-4030 F/T 1 (PE, SP)WALNUTTein Chun Wang, DDS #3644011309 N Grand Ave 909-594-7899 F/T 1 (CA, CH, SP)Walnut Hills Family Dentistry #00065218758 Amar Rd 626-912-5599 P/T 2 (FR, SP, AR)WALNUT PARKAlameda Dental Group #0271657700 Alameda St # A 323-585-9200 P/T 1 (Sp) U

WEST COVINAAmerican Dental Group #031087436 N Sunset Ave 626-337-7271 F/T 1 P/T 1Bright Now Dental #0135961400 W West Covina Pkwy 626-338-4848 F/T 3 P/T 10 (SP) U

Dental Care By Blanco #002091 1031 E Amar Rd 626-330-6655 F/T 1 (SP) U

Dental Max #0289352360 S Azusa Ave Ste B 626-839-5010 F/T 1 (SP)Garvey Dental Office #0140451415 W Garvey Ave N Ste 101 626-851-0020 P/T 1 (SP, TA) U

Gateway Dental and Braces #029566662 S Sunset Ave 626-337-9494 F/T 3 P/T 1 (PE, SP) U

Gina Barrameda, DMD #0040741519 E Amar Rd 626-964-6799 P/T 2 (TA) U

Joven Professional Dtl Corp #031443150 S Glendora Ave 626-919-2322 F/T 2 (SP, TA) U

Lin Ma, DDS #017943358 N Azusa Ave 626-966-4514 F/T 1 (SP, CH)Maninder Singh, DDS #3148011312 W Francisquito Ave # D4 626-918-0171 F/T 1 (HI, SP)Newport Dental #003510151 N Azusa Ave 626-331-0076 F/T 3 P/T 15 (SP)Queens Dental Group #329601910 S Sunset Ave Ste 4 626-337-6166 F/T 2 P/T 1 (HI, SP, TA, VI)Rafik Yanni, DDS #2210012413 S Azusa Ave 626-913-1421 F/T 3 (AR, SP, VI) U

Robert Dinh, DDS., Inc #0228841414 S Azusa Ave Ste B-16 626-919-0415 F/T 1 (SP, VI)Smartcare Dental Practice #011835415 S Glendora Ave Ste A 626-918-8338 F/T 1 (SP, TA)Smilecare-West Covina #0035121215 W West Covina Pkwy 626-962-8911 F/T 1 P/T 7 (SP) U

Southern Calif Dtl Ser #3550011014 S Glendora Ave 626-918-2886 F/T 1 (CH, SP)West Covina Family Dentistry #160201450 S Glendora Ave Ste 106 626-856-3317 F/T 2 P/T 7 (HI, SP, RU, TH) U

West Covina Smiles #0184913660 S Nogales St Bldg H #D 626-810-9600 F/T 1 (SP) U

WEST HILLSFallbrook Dental Group #0213926739 3/4 Fallbrook Ave 818-592-6060 F/T 1 (PE, SP) U

Gentle Dentistry #0234727138 Shoup Ave Ste B7b8 818-883-7070 F/T 1 U

Medical Center Dental Care #0107917325 Med Ctr Dr Ste 101 818-348-6068 P/T 1 (SP) U

Platt Village Dental Group #0157346446 Platt Ave 818-716-7001 P/T 2 (SP) U

Stephen Cheung, DDS #01326623101 Sherman Pl Ste 417 818-348-9595 F/T 1 (CA, PE, HE, SP) U

WEST HOLLYWOODA West Hollywood Sunset Dtl #0175289201 W Sunset Blvd Ste 808 310-858-8656 P/T 1 (HE, PE, SP) U

Eva Dloomy, DDS #3930019201 W Sunset Blvd Ste 501 310-278-9121 F/T 1 (AR, FR, HE, SP) U

Omid Farahmand, DMD #0118419201 W Sunset Blvd Ste 915 310-273-3650 F/T 1 (PE) U

WESTCHESTERBenjamin Rosenberg, DDS #0027828540 S Sepulv Blvd Ste 1000 310-649-2430 F/T 1 (SP, HE) U

Westchester Dental Care #1610018930 S Sepulv Blvd Ste 117 310-641-8890 F/T 1 (SP, TA, PE) U

WESTLAKE VILLAGEFinesse Dental Care #016471860 Hampshire Rd Ste E 805-777-7447 P/T 1 (HE, SP) U

Ghotanian DDS PC #001508870 Hampshire Rd Ste C 805-497-2260 F/T 2 (SP) U

Sona Georgian, DDS #01174032144 Agoura Rd Ste 213 818-991-4664 F/T 1 (AM, RU, Sp)WESTMINSTERNewport Dental #00449115458 Beach Blvd 714-898-3220 F/T 6 P/T 11 (SP, VI) U

Thanh Ngoc Nguyen DMD Inc #11540115355 Brookhurst St Ste 101 714-531-5175 F/T 2 (VI) U

WHITTIERAtlantic Dental Group #0049096716 Greenleaf Ave 562-696-5544 F/T 2 (PE, SP) U

Beverly Family Dental #01747711822 Floral Dr Ste D 562-692-7870 F/T 1 (PE)Darrel Dagdigian, DDS #25180116406 Whittier Blvd 562-694-0396 F/T 2 (KO, SP, VI) U

Friendly Hills Fmly Dentistry #39670114544 Whittier Blvd 562-698-9855 F/T 1 (HI, SP) U

Merle Yaneza, DDS #01972510420 Whittier Blvd 562-463-3332 P/T 1 (SP, TA)Mitra Rouintan, DDS #0251929209 Colima Rd Ste 2200 562-693-4108 F/T 1 (PE, SP)Rodolpho Burquez, DDS #00002611574 Hadley St 562-699-3838 F/T 1 U

So Cal Family Dentistry #00250114412 Whittier Blvd 562-693-0788 F/T 1 (SP, PE)St Mary Medical Building #0229987743 Painter Ave Ste B 562-698-7113 P/T 1 (SP)The Village Dental Center #0160106742 Greenleaf Ave Ste 300 562-945-1684 F/T 1 (SP, HI)Thomas Trinh, DDSInc #0203079150 Painter Ave # 105 562-320-3333 F/T 1 (SP) U

Uptown Dental Group #0131586711 Greenleaf Ave 562-698-0054 F/T 1 (CH, SP) U

Whittier Dental Center #28350114564 Whittier Blvd 562-693-8202 F/T 1 P/T 1 (PE, KO, SP)WILDOMARBear Creek Dental Group #01129136068 Hidden Springs Rd # H 951-678-0790 F/T 1 P/T 1 (SP) U

Clinton Keith Dental Group #01072323905 Clinton Kth Rd Ste 108 951-304-9700 P/T 1 (SP)Upland Dental Implnt & Ortho #02170234859 Fredrick St Ste 106 951-678-9888 P/T 1 (SP, CH) U

Wildomar Dental Care #02627232100 Clinton Keith Rd Ste E 951-678-4300 F/T 1 (SP, VI)WILMINGTONDental Office #017527445 E Anaheim St Ste M 310-835-3535 P/T 1 U

Jin Yang, DDS #016541200 E Anaheim St Ste 254 310-830-3344 F/T 1 (SP) U

Lucy Cabieles, DDS #0186061455 N Avalon Blvd 310-835-1842 F/T 1 (SP) U

Vaishali Patel, DDSInc #021646207 W G St 310-549-2400 F/T 1 (SP, HI, EI)Wilmington Dental #0127401610 N Avalon Blvd 310-835-3131 F/T 4 P/T 8 (PE, SP)Wilmington Family Dentistry #002867851 W Pacific Coast Hwy 310-830-3620 F/T 1 (KO, SP) U

WINCHESTERWinchester Dental Center #1C510133040 Simpson Rd 951-926-2489 F/T 1 (KO, SP)WINNETKAEdwin Papazian DDS., Inc #0028537616 Winnetka Ave Ste 1 818-772-6222 F/T 1 (AM, SP, PE) U

Sky Dental Group #02386419725 Vanowen St 818-347-6060 F/T 1 (PE, SP)WOODLAND HILLSAffinity Dental Group #0305535312 Comercio Ln Ste B 818-884-4338 P/T 1Around The Corner Dental Spa #01139822030 Clarendon St Ste 102 818-999-4445 F/T 1 (PE, SP, TA)Cosmetic Laser Dentistry #01573522062 Ventura Blvd 818-676-1485 P/T 1 (SP, GE, AR)Ebrahim Mikail, DDS #01227922636 Ventura Blvd 818-591-0123 F/T 1 (PE) U

Edward Rosen & Associates #01368921500 Ventura Blvd Ste 200 818-999-6165 F/T 2 P/T 3 (AM, CH, PE, RU, SP) U

Hamid Imankhan, DDS #02312723111 Ventura Blvd Ste 104 818-225-7768 F/T 1 (SP, PE, FR)Nader Ahdout, DDS #00282922116 Ventura Blvd 818-340-3062 F/T 1 (SP, PE)Pivnick And Rosen DDS #0C80016325 Top Cyn Blvd Ste 518 818-346-8840 F/T 1 P/T 1 (SP) U

Taft Plaza Dental Group #02782520046 Ventura Blvd 818-716-0297 F/T 3 (AM, SP, FR, RU, PE) U

Topanga Dental Care #02040421839 Ventura Blvd 818-347-8444 F/T 1 (AR, AM, SP) U

YORBA LINDAEastlake Village Dental #01556320429 Yorba Linda Blvd 714-695-9530 P/T 2 (SP, PE) U

Nilar Thein, DDS #00636117540 Yorba Linda Blvd 714-996-4057 P/T 2 (SP) U

Richard Hamaty, DMD #01752218509 Yorba Linda Blvd 714-779-1313 P/T 1Yorba Linda Dental Arts #02202019831 Yorba Linda Blvd Ste A 714-693-0990 P/T 2 (PE) U

Yorba Linda Dental Center #16040121560 Yorba Linda Blvd Ste C 714-779-7675 F/T 2 (CH, SP) U

Yorba Linda Dental Group #01153918432 Yorba Linda Blvd Ste D 714-970-2801 P/T 2 U


Kaiser Permanente is pleased to offer Federal employees and eligible Federal retirees and dependents who are currently enrolled or planning to enroll in Kaiser Permanente’s Traditional HMO plan a choice of the dental plans described below. Option 1 is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., and is administered by Delta Dental of California (Delta Dental). Option 2 is a DeltaCare® USA Dental Health Care program provided by Delta Dental of California. These benefits are neither offered nor guaranteed under a contract with the Federal Employees Health Benefit (FEHB) Program, but are made available to all enrollees and family members who become members of Kaiser Permanente.

During the annual open season period, you have the opportunity to enroll in one of the two plans. If you are already enrolled, you may change plans during this period. Your coverage under the enrolled plan will become effective on January 1, 2011 and will extend through December 31, 2011, subject to your continued premium payments and enrollment in Kaiser Permanente’s Traditional HMO Plan. If you are already enrolled under one of the two dental plans and are not planning on changing your coverage, you do not need to complete the enrollment form. If you are changing plans, you must provide 30-days advance written notice of termination. If you are covered under Option 1, the notice must be sent to Delta Dental (see page 7 for address). If you are covered under Option 2, the notice must be sent to DeltaCare USA (see page 18 for address).

You have two dental plans to choose from:

2 DeltaCare USA is a dental HMO program, administered by Delta Dental. With DeltaCare USA, you select a conveniently located network dentist to provide dental care for you and

your family. A list of participating network dentists is enclosed for your review. Depending on the service you receive, you pay either a small copayment or no copayment at all. With the DeltaCare USA program, there are no deductibles and no claim forms.

1KPIC’s Group Dental Insurance Plan allows you the freedom to see any licensed dentist of your choice. It uses a Table of Allowances that lists the dollar

amount KPIC will pay for each covered dental service. A copy of the Table of Allowances is included in this brochure.

Remember that you are enrolling in your selected dental plan for a period of one year. This does not apply if your employment is terminated. Payment for either the KPIC or Delta Dental plan will be automatically withdrawn from the checking, savings or credit union account you specify. To review a brochure of the program, visit kp.org/feds.

For questions about KPIC’s Dental Insurance Plan, contact Delta Dental at: 888-335-8227 - Monday through FridayYour Kaiser Federal group number is #9874 8 a.m. - 4 p.m. Pacific time

For questions about DeltaCare USA, contact Delta Dental at: 800-422-4234 - Monday through FridayYour Kaiser Federal group number is #1114 5 a.m. - 6 p.m. Pacific time

Monthly KPIC Premium* Dental Insurance Plan

Self Only $29.03 Self & One Party $51.44 Self & Two or More $77.32


With KPIC's Group Dental Insurance Plan . . . With DeltaCare USA . . . • You have the freedom to choose any licensed dentist.

• Each family member may visit a different dentist.

• Table of Allowances lists the specific dollar amountpayable for each covered dental service.

• Orthodontic services are not covered.

• Claims paperwork is handled for you when you see one of Delta Dental’s approximately 30,000 participating dentist locations in California.

• There is a deductible of $50 per person ($150 maximum per family); the maximum the program covers annually is $1,000 per person.

• There is no deductible for diagnostic and preventive services.

• Some procedures are subject to waiting periods

• You select one of the more than 6,200 network dentists statewide.

• General dental care for the entire family is provided by a network dentist.

• You pay a modest or no copayment for covered services.

• Orthodontic services with a copayment of $1,600 for children under 19 and $1,800 for covered adults and dependent adult children.

• There are no claim forms to complete.

• There are no deductibles.

• There are no annual maximums except for accidental injury.

DeltaCare USA Monthly* Quarterly* Self Only $ 11.89 $ 35.67 Self & One Party $ 19.90 $ 59.70 Self & Two or More $ 30.17 $ 90.51


See Green Section Beginning on Page 1 See Blue Section Beginning on Page 9

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YUCAIPAImperial Dental Practice #00092534880 Yucaipa Blvd 909-797-1136 F/T 1 P/T 1 (SP)Yucaipa Family Dentistry #15760134488 Yucaipa Blvd Ste F 909-797-0303 F/T 1 (GE, JA, KO, SP, RO)YUCCA VALLEYY. Chang, DDS #0116317024 Airway Ave Ste A 760-365-2351 F/T 1 (KO, SP)

ALISO VIEJORobert Murray, DDS #271701949-831-4655 P/T 1 (KO, SP, TA, VI) U

ANAHEIMDrs Anthony and Naomi Wong #256401714-995-3051 F/T 1 P/T 1 (CA, CH)F Foroutan, DDS Inc #000219714-693-1889 F/T 1 (PE, SP)Nandini Murthy, DDS #183601714-774-2638 P/T 1 (SP, HI)ARCADIABingzhong Fang, DMD #007863626-254-9066 F/T 1 (CH)BAKERSFIELDJavier Central Valley Dental #018808661-323-0076 F/T 1 (SP, TA) U

Kenneth Krauss, DDS #131001661-323-8585 F/T 1Premier Family Dentistry #020862661-324-1200 F/T 1 (KO, SP)BALDWIN PARKLuis Alvarado, DDS #025183626-856-3456 F/T 2 (SP)BELLFLOWERBenjamin Woo, DDS #354901562-925-3715 F/T 1 (CH, SP, TA)BEVERLY HILLSLilia Agadganian, DDS Inc #012471310-652-8877 F/T 1 (AM, RU, SP) U

CARLSBADAvia Dental Care #033158760-431-7711 F/T 1COMPTONQureshi Compton Fmly Dtl #2C6401310-639-5330 F/T 1 (SP)Shailesh Parikh, Dds #038101310-639-7970 F/T 1 (Sp)CULVER CITYCulver City Family Dental Ctr #018123310-642-5999 F/T 1 (SP) U

Gary Wirtschafter, DDS #374401310-839-8033 F/T 1 (FR, SP) U

Steven Seldon, DDS #381601310-204-0700 F/T 1Warren Kaufman, DDS #041701310-838-7780 F/T 2 P/T 1 (SP)

CYPRESSSamuel Au, DDS #012688714-826-9988 F/T 1 (CH, KO) U

DOWNEYRichard Lee, DDS #019414562-622-1948 F/T 1 (SP) U

Wilk Peery, DDS Inc #023828562-862-4543 F/T 1 (Sp)DUARTESaleh Kholaki, DDS #366801626-301-4220 F/T 1 (AR, SP)ENCINOFirouzeh Banki, DDS #3C0301818-990-5900 F/T 1 P/T 1 (SP) U

FOUNTAIN VALLEYPaul Jaruszewski, DDS #260701714-963-3005 F/T 1 (SP) U

FULLERTONFamily Dental #174601714-525-4538 F/T 1 (AR, SP, HI) U

GARDEN GROVEBristol Dental Group #353101714-638-9999 F/T 1 (SP) U

GLENDORASan Dimas Dental Group #023401626-857-4702 F/T 2 P/T 1 U

GRANADA HILLSFamily Dentistry #000632818-832-2087 F/T 1 (SP, TA)HACIENDA HEIGHTSRonald Nichols, DDS #324801626-912-9394 F/T 1 (SP) U

HAWTHORNEBurton Schnierow, DDS #286801310-679-0106 F/T 4 (AR, CH, FR, SP, TA) U

Santa Maria Dental Ofc #003889310-973-0945 F/T 1 (SP)HEMETSmile Shop #017951951-306-0987 F/T 1 (SP) U

HESPERIAL Mowery, DDS Inc #360701760-244-5047 F/T 1 P/T 1 (SP) U

HUNTINGTON BEACHArthur Cabrera, DDS #305601714-965-6025 F/T 1 (SP) U

Gabriel Capdevila, DDS #151801714-846-2895 F/T 1 (SP)INDIAN WELLSClark Cressman, DDS #006624760-836-0052 P/T 1 (SP)IRVINEGrace Han, DMD #021494949-502-6406 F/T 1 (KO, SP) U

LA HABRAHarbor Dental #1C2401562-690-3551 P/T 1 (CH, SP) U

Juliet Chua, DDS #355701562-691-7438 F/T 1 (CH, SP, TA) U

LA MESASmilehaven Dental Center #358801619-464-2801 P/T 1 (TA)LADERA RANCHSerene Family Dentistry #032353949-218-4000 F/T 1 (PE, SP) U

LONG BEACHDr Willard Hankins Jr #026087562-421-8206 F/T 1 (SP)LOS ANGELESArturo Ibarra, DDS #003990323-260-7173 F/T 1 (SP)Arturo Ibarra, DDS #003991323-221-3165 F/T 1 (SP)Belinda Balais, DMD #002777213-229-0005 F/T 1 (SP, TA)Culver City Mar Vista Dental #012166310-398-6161 P/T 1 (HE, PE, SP)George Tay Family Dentistry #000634323-227-9885 F/T 1 (CH, SP) U

RK Chetty DDS Inc #041801323-258-2885 F/T 2 (SP, HI) U

Shaw Adams Dental Group #092401323-933-5641 F/T 1 (SP)MISSION VIEJOMontgomery & Kiriak DDS #3C0601949-347-0807 F/T 1 P/T 1 (GE, SP)MORENO VALLEYWilliam Kohl, DDS #202601951-924-9831 F/T 1NATIONAL CITYCivic Center Dental Group #321901619-474-6200 F/T 1 (SP, TA)NORTH HOLLYWOODAlan Brody, DDS #209401818-762-2682 F/T 1 (SP, GR, HI) U

NORTHRIDGEAll Family Dental Care #3C7201818-709-9988 F/T 1 (SP)Raffi Najarian, DDS #008628818-363-7469 P/T 1 (AM, SP)NORWALKRalph Nicassio, DDS #283601562-868-7768 F/T 2 (SP) U

OCEANSIDEOcean Ranch Dentistry #028067760-453-2900y F/T 2 (SP, VI) U

ORANGEOrange Dental Arts #029282714-538-2400 F/T 1PALMDALEC.I. Dentistry #026341661-947-2400 F/T 1 (SP) U

Y Siani, DMD #375601661-947-6782 F/T 1 (SP) U

PASO ROBLESDavid Krill, DDS #000940805-239-2146 F/T 2 (SP) U

RANCHO SANTA MARGARITA Platinum Dental #013496949-888-0806 F/T 2 U

REDLANDSJohn Cesario, DDS #002339909-798-7228 F/T 1

RIVERSIDEIndian Hills Dental #010408951-361-0443 F/T 1 (SP) U

Nat Shain, DDS #153101951-788-4500 F/T 1Vivian Kwon, DDS #172501951-689-8544 F/T 1 (KO, SP)Wei Min Tu, DDS Inc #021699951-343-1211y (CH, SP) U

ROWLAND HEIGHTSMichael Chan, DDS #372101626-913-0222 F/T 1 (CH, SP) U

SAN DIEGORancho Bernardo Town Ctr #023306858-451-2555 F/T 1 (SP, VI) U

SAN JUAN CAPISTRANOKirk Hobock, DDS #285601949-493-6006 F/T 1 (SP) U

SAN MARCOSMichael Nelson, DDS #268801760-471-9560 F/T 2SANTA ANAJason Sang Lee, DDS Inc #022068714-547-7379 F/T 1 U

SHERMAN OAKSGus Huerta, DDS #391701818-995-8484 F/T 1 (SP, RO) U

TOLUCA LAKENajarian And Najarian DDS #120301818-769-1111 F/T 1 (AM, PE)TORRANCESouth Bay Family Dental Group #340001310-539-5566 F/T 2 P/T 1 (AM, SP, HR)VAN NUYSCalifornia Smiles Dental Grp #021219818-908-9800 F/T 2 (AM, AR, PE, SP) U

WEST COVINAEdison Der, DDS #002401626-858-3305 F/T 1 U

Gerald V Garcia, DMD Inc #016879626-338-7092 P/T 1 (TA, SP)Gregory Robins Fmly Dnstry #383201626-919-7707 F/T 1 P/T 2 (GE, KO, FR, SP) U

Katherine Forbes, DDS #370401626-939-0639 F/T 1 (SP)WESTMINSTERBoyd Joyer Jr, DDS #357801714-893-2411 F/T 1 U

WOODLAND HILLSThomas Bartle, DMD #134301818-224-2095 F/T 1 (SP)Viken Toutounjian, DDS #395901818-348-3801 F/T 1 (AR, AM, RU) U


Visit us at our website: www.deltadentalins.com/deltacareusa. NOTE: The “01” listed at the end of each provider number shown is for internal use only. The provider selection will be honored whether OR NOT the “01” is noted on the enrollment form.Additional Dental Offices will be added as required. You may call the DeltaCare USA Customer Service department at 800-422-4234 for updates to the provider list. If any office is closed to further enrollment, Delta Dental reserves the right to assign you another dental office as close to your home as possible.

Southern CaliforniaClosed Offices

17871 Park Plaza Drive, Suite 200Cerritos, CA 90703

KPIC’s dental program information: 800-933-9312DeltaCare USA information: 800-422-4234

E (rev. 9/10) #59331 KA5 SA-01-904-05

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