Gatton & Associates
Insurance Agency
313 Eastern Blvd.
Baltimore, MD 21221
410-682-5517
       
Maryland Preventive Dentistry Program
Enrollment Form

For immediate enrollment call 410-682-5517 to enroll by telephone
using your VISA or MASTERCARD.

Complete and mail to:

Gatton & Associates
313 Eastern Blvd.
Baltimore, MD 21221

Make check payable to Gatton & Associates

 

Print your name:

 

Street Address:

 

City - State - Zip Code

check one:

 

 

 

 

 

 

Enclose:
Annual Individual $59.00 ____
Annual Family $99.00____

 

Home Telephone:

 

Work Telephone:

 

Social Security Number :
Mail or fax to:

Gatton & Associates
313 Eastern Boulevard
Baltimore, MD 21221

Phone: 410-682-5517 - Fax 410-656-9677