Springfield Pre-Paid Dental Coverage

Giving You Comprehensive Coverage at an Affordable Price

Cost Options:

• For a single: $17.60 per month
• For a single plus one: $25.25 per month
• For a family: $30.15 per month

To become a plan member, simply fill out the attached application. Make sure you check which payment method you prefer: either the convenient Monthly Bank Draft or the Annual Payment, and then mail to Dental Source at the address listed on the Enrollment Form.

If you choose the Monthly Bank Draft method, please enclose a check for the first month’s membership and the enrollment fee. If the Annual Payment is selected, please enclose a check for the annual rate plus enrollment fee.

For More Information, Contact:

American Dental Program Agency
Representing Dental Source

1722 South Glenstone, Suite W-201
Springfield, MO 65804

(417) 882-3787
* (800) 955-3471

Fax: (417) 886-5852