SHEPS CENTER DATA REQUEST FORM
NC Health Professions Data
Dentist and Dental Hygienist Data
Fill out this form, print, and fax it to:
NC Board of Dental Examiners
507 Airport Blvd., Suite 105
Morrisville, NC 27560-8200
Mr. Bobby White, Chief Operations Officer
Phone: (919) 678-8223
Fax: (919) 678-8472

Attach a separate page describing the intended use for the labels/listing. Once approval has been received by the Sheps Center, you will be contacted with an estimated price and delivery date of the output. Contact the Sheps Center Data Coordinator at nchp@unc.edu or (919)966-7112 if you have questions or need additional information.

NOTICE: Data are provided by the NC Board of Dental Examiners as of October each year and compiled by the Sheps Center. Address changes are made only at the time of the annual update. Contact the Sheps Center Data Coordinator at (919) 966-7112 for more detailed information regarding the Sheps Center files.

Requester's Name:
Business Name:
Address:
City, State & ZIP:
Telephone Number:
Fax Number:
Email Address:
Type of Organization: For-Profit (FP)     Non-Profit (NP)

Electronic Output Request Type: Check one or more
Name, address, specialty, county ($4.50/100 names: $100.00(NP)/$200(FP) minimum)
All data available ($7.00/100 names: $200.00(NP)/$300(FP) minimum)

Output format:
 Tab-delimited Comma-delimited Fixed Field
Other (please specify):

SELECTION CRITERIA (check all that apply):

Profession: Dentist   Dental Hygienist

Activity Status: Active   Inactive

Area Selection: In-state   Out-of-state
Specific counties:
Other (please specify)

Practice Setting:
Unknown
Hospital - Non-federal
Nursing Home - Non-federal
Clinic - Non-federal
Group Health - Non-federal
Practice Office - Non-federal
Other - Non-federal
Federal Health - Military
VA, Public Health, Indian Health (Federal)
Other Federal
School, Education
Other Type

Form of Employment:
Unknown    Solo(self-employed)   Non-solo (self-employed)    Individual Practitioner
Partnership/Group    County Government    State Government    Federal Government
Other


Primary Specialty: (for dentists only)
Unknown    General Practice    Endodontics    Oral Pathology    Oral Surgery
Orthodontics    Pedodontics    Periodontics    Prosthodontics    Dental Public Health

Description of Request: List other details of your request in the box below.


What order do you want the output sorted in?

For NC Board of Dental Examiners Use Only:
Approved by:______________________________________________  Date:________

Note to Board: Please send this form with approval to the Sheps Center Data Coordinator:
Fax (919) 966-5764.

Updated 2/16/07