TDA ELITE CHOICE GROUP DENTAL PLAN IN-NETWORK OUT-OF-NETWORK

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1 Total Dental Administrators, Inc E Highland Avenue, Suite 250 Phoenix, Arizona (602) or (888) Valley City State University employees: Total Dental Administrators, Inc. (TDA) is pleased to offer the Elite Choice dental benefit plan option to you during the Plan Year The Elite Choice Plan is designed to encourage you to visit the dentist and help ensure your basic dental needs are met in a timely and cost effective manner. Our plan offers you the option of receiving your dental care from any dentist you choose (Out of Network) or from any Participating Plan Dentist (In-Network). However, if you elect to receive your dental care from an In-Network dentist, you re out of pocket costs will be less. Highlights of the TDA Elite Choice Group Dental Plan are as follows: TDA ELITE CHOICE GROUP DENTAL PLAN IN-NETWORK OUT-OF-NETWORK Calendar Year Deductible None $50 per person / $150 per family Class 1: Preventive & Diagnostic Class 2: Restorative / Fillings Class 3: Crowns, Endo, Perio, Prosthodontics, Oral Surgery Copays Copays Copay Deductible is Not Applicable Plan Pays Allowance to Provider Enrollee may be Balance Billed Deductible is Applicable Plan Pays Allowance to Provider Enrollee may be Balance Billed Deductible is Applicable Plan Pays Allowance to Provider Enrollee may be Balance Billed Balance Billing Allowed No Yes Waiting Periods None Six (6) months for Class 3 Services Annual Benefit Maximum Total Maximum of $2,000 per Covered Person (For a complete list of covered services and limitations/exclusions, please refer to the Dental Benefit Plan Summary) Employee Only Employee + 1 Dependent Employee + 2 or More Dependents 2018 Monthly Rates $31.80 $59.98 $99.96 You are eligible to enroll on the TDA Elite Choice Dental plan if you are an employee of: The State of North Dakota North Dakota State University Minot State University Dickinson University North Dakota State College of Science University of North Dakota Valley City State University Bank of ND Garrison Diversion District Mayville State University Williston Stat College Bismarck State College District Health Units Attached are the TDA Elite Choice Dental Plan Summary of Benefits Brochure, Enrollment form, Provider Directory and a Provider nomination form. You may also search for contracted providers on TDA s Web site at If you have any questions, please feel free to call or TDA s representatives for assistance. Ron Holden (701) rholden@minot.com or Chris Jehle (602) chrisjehle@cox.net Thank you and we look forward to serving you in 2018.

2 GROUP DENTAL ENROLLMENT FORM New Employee Add Coverage Add/Delete Dependent Decline Coverage Cancel Coverage Address/Name Change Loss of Other Coverage Transfer From DHMO Transfer From PPO COBRA Enrollment Name of Employer: (Use Name from Group Billing Notice or Master Application) Plan Types: Valley City State University Elite Choice Group Number: Class: Social Security Number Effective Date Month / Day / Year Date Employed Fulltime Month / Day / Year Hours Worked Per Week Your Name (Last), (First), (MI) Home Address: Date of Birth Month / Day / Year Sex: Coverage Requested: Male: Female: Home Phone Number: Work Phone Number: Do you have any other Dental coverage? If so, Carrier. Employee Only Employee + 1 Employee + Family Complete for Dependent Coverage: Spouse Name: (Last), (First), (MI) C H I L D R E N Sex: 1. / 2. / 3. / 4. / 5. / 6. / Date of Birth: Do any of your dependents have any other dental If so, Name of Carrier: coverage? Fraud Warning (Not Applicable in AZ): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I elect the dental coverage selected for which I am eligible. If any contribution from me is necessary to pay part of the cost of insurance. I authorize my employer to deduct the contribution from my wages. Date Refusal of Group Dental Coverage: I have been offered this insurance coverage and decline to purchase it at this time. I understand that in the event I desire such insurance at a later date, I will be required to furnish evidence of insurability at my own expense, and the company will have the right to refuse any request. Date Employee Signature: Employee Signature: Return To: Total Dental Administrators, Inc East Highland Avenue, Suite 250 Phoenix, AZ

3 Elite Choice Group Dental Plan The State of North Dakota Employees of the State of North Dakota, the University System, District Health Units and Garrison Diversion Conservancy District are eligible to participate in this plan ProviDent 2111 East Highland Avenue, Suite 250 Phoenix, Arizona R (FAX)

4 ELITE CHOICE GROUP DENTAL PLAN Welcome to the ELITE CHOICE GROUP DENTAL PLAN available exclusively from Total Dental Administrators. The ELITE CHOICE DENTAL PLAN offers you the option of receiving your dental care from any dentist you choose (Out-Of-Network) or from any Participating Plan Dentist (In-Network); and you don't need to make that decision until you need dental care! However, should you elect to receive your dental care from an In-Network dentist, your out of pocket costs will be less. The following is an outline of your dental coverage. For a complete listing of procedures please refer to the employee booklet/certificate you will receive after enrollment. Services not listed are available on a fee for service basis, no discount applies. Elite Plan Advantages No In-Network Deductibles $2,000 Annual Maximum No In-Network Waiting Period (6 Month Waiting Period for Major Services Out-Of-Network) Utilizing An In-Network Dentist There are no deductibles for dental services provided by participating In-Network dentists. Co-pays in the column titled In-Network apply to services performed by participating In- Network dentists only. The member is responsible for the amount listed under the In-Network Patient Co-pay. Utilizing An Out-Of-Network Dentist There are no deductibles for Diagnostic or Preventive (Class I) services. A $50.00 per person and $ per family annual deductible will be applied to all dental services not listed in the Diagnostic and Preventive (Class I) categories. Members must meet a 6-month waiting period for all Major (Class III) services. The fees listed in the column titled Out-Of-Network are what the plan covers toward those services. The member is responsible for the difference between the amount paid by the plan, and the amount your dentist charges. The member is therefore responsible for any balanced-billed amount. Code Description CLASS I DIAGNOSTIC In-Network Patient Copay Out-of-Network Plan Pays to Dentist, Patient responsible for difference D0120 Periodic Oral Evaluation No Charge $32.00 D0140 Limited Oral Evaluation No Charge $47.00 D0150 Comprehensive Oral Evaluation No Charge $53.00 D0180 Comprehensive Perio Oral Eval No Charge $51.00 D0210 Intraoral-Complete Incl Bitewings No Charge $85.00 D0220 Intraoral - Periapical First Film No Charge $21.00 D0230 Intraoral-Periapical- Ea Addl Film No Charge $16.00 D0272 Bitewings- 2 Films No Charge $35.00 D0274 Bitewings- 4 Films No Charge $44.00 D0277 Vertical Bitewings- 7-8 Films No Charge $65.00 D0330 Panoramic Film No Charge $80.00 CLASS I PREVENTIVE D1110 Prophylaxis-Adult $15.00 $48.00 D1120 Prophylaxis-Child $10.00 $33.00 D1206 Topical application of fluoride varnish No Charge $43.00 D1208 Topical application of fluoride No Charge $25.00 D1351 Sealant- per tooth $15.00 $17.00 D1510 Space maintainer-fixed-unilateral No Charge $ D1515 Space maintainer - fixed bilateral No Charge $ CLASS II RESTORATIVE D2140 Amalgam-1 surface $55.00 $35.00 D2150 Amalgam- 2 surfaces $55.00 $54.00 D2160 Amalgam-3 surfaces $65.00 $75.00 D2161 Amalgam-4 or more surfs $65.00 $97.00 D2330 Resin-1 surface, anterior $65.00 $47.00 D2331 Resin-2 surfaces, anterior $70.00 $69.00 D2332 Resin-3 surfaces, anterior $75.00 $85.00 D2335 Res-4 or more surf-invl inc angle ant. $95.00 $ D2390 Resin-based composite crown, anterior $ $ D2391 Resin-based composite - 1 surf, post $70.00 $45.00 D2392 Resin-based composite - 2 surf, post $85.00 $85.00 D2393 Resin-based composite-3 surf post $95.00 $97.00 D2394 Resin-based composite-4 or more surf, post $ $ CLASS III RESTORATIVE D2510 Inlay-metallic-1 surface $ $ D2520 Inlay metallic -2 surfaces $ $ D2530 Inlay-metallic 3 or more surf $ $ D2740 Crown-porcelain ceramic substrate $ $ D2750 Crown-porcelain-high noble metal $ $ D2751 Crown-porcelain-predom base metalic $ $ D2752 Crown-porcelain fused-noble metal $ $ D2790 Crown-full cast high noble metal $ $ D2930 Crown - Prefabricated Stainless Steel - Primary tooth $ $58.00 D2932 Prefabricated resin crown $ $ D2950 Core build-up, including any pins $ $ R1

5 Code Description In-Network Patient Copay Out-of-Network Plan Pays to Dentist, Patient responsible for difference CLASS III RESTORATIVE CONTINUED D2951 Pin ret/tooth, in add-restoration $25.00 $12.00 D2952 Cast post and core in add to crown $ $ D2954 Prefab post/core in add to crown $ $84.00 D2980 Crown repair, by report $75.00 $34.00 CLASS III ENDODONTICS D3110 Pulp cap-direct (exc final rest) $30.00 $15.00 D3120 Pulp cap-indir (exc final rest) $25.00 $14.00 D3220 Thera pulpotomy (exc final rest) $75.00 $32.00 D3310 Root canal-anterior (excl finl rest) $ $ D3320 Root can-bicuspid (excl fnl rest) $ $ D3330 Root canal-molar (excl final rest) $ $ D3346 Retreat Prev Root Canal - Anterior $ $ D3347 Retreat Prev Root Canal - Bicuspid $ $ D3348 Retreat Prev Root Canal - Molar $ $ D3410 Apicoectomy/periradicular surg-antr $ $ D3421 Apicoectomy/Periradicular surg-bicusp- D3425 1st Rt $ $ Apicoectomy/Periradicular surg-molar 1st Rt $ $ D3430 Retrograde filling-per root $95.00 $82.00 D3450 Root amputatuion-per root $ $ CLASS III PERIODONTICS D4210 Gingivectomy or gingivoplasty-quad 4 or more teeth $ $ D4211 Gingivectomy or gingivoplasy-tooth 1 to 3 teeth $80.00 $62.00 D4240 Ging flap proc inc root plng/quad 4 or more teeth $ $ D4241 Ging flap proc inc root plng/tooth 1 to 3 teeth $95.00 $ D4341 Perio scaling & root plng-quad 4 or more teeth $ $71.00 D4342 Perio scaling & root plng-tooth 1 to 3 teeth $55.00 $44.00 D4355 Full mouth debride-enable eval & dx $65.00 $42.00 D4910 Perio maint proc following act ther $55.00 $43.00 CLASS III REMOVABLE PROSTHODONTICS D5110 Complete denture maxillary $ $ D5120 Complete denture-mandibular $ $ D5130 Immediate denture-maxillary $ $ D5140 Immediate denture-mandibular $ $ D5211 Maxillary part denture-resin base $ $ D5212 Mandibular part denture-resin base $ $ D5510 Repair broken comp denture base $65.00 $48.00 D5520 Replace miss/brkn teeth-comp dent $65.00 $34.00 D5610 Repair resin denture base $60.00 $67.00 D5630 Repair or repl brkn clasp, pd $ $60.00 D5640 Replace brkn teeth/ tooth, pd $60.00 $43.00 D5650 Add tooth to existing pd $ $51.00 D5660 Add clasp to existing pd $ $74.00 D5850 Tissue conditioning, maxillary $60.00 $39.00 D5851 Tissue conditioning, mandibular $60.00 $39.00 D6210 Pontic-cast high noble metal $ $ Code Description CLASS III IMPLANTS In-Network Patient Copay Out-of-Network Plan Pays to Dentist, Patient responsible for difference D6010 Surgical placement of implant: endosteel implant. $ $ D6056 Prefabricated abutment includes placement. $ $ D6057 Custom abutment includes placement $ $ D6058 Abutment supported porcelain/ceramic crown. $ $ D6059 Abutment supported porcelain fused to metal crown (high noble metal). $ $ D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) $ $ D6061 Abutment supported porcelain fused to metal crown (noble metal) $ $ D6062 Abutment supported cast metal crown (high noble metal). $ $ D6063 Abutment supported cast metal crown (predominantly base metal) $ $ D6065 Implant supported porcelain/ceramic crown. $ $ CLASS III ORAL SURGERY D7111 Extraction, coronal remnants-deciduous tooth $35.00 $34.00 D7140 Extraction, erupted tooth or esposed root $55.00 $44.00 D7210 Surg rem erup tooth req flap/bone $ $57.00 D7220 Remov of impacted tooth-soft tis $ $65.00 D7230 Remov of impacted tooth-par bony $ $81.00 D7240 Remov of impacted tooth-comp bony $ $93.00 D7241 Remov of impacted tooth-comp bony, complicated $ $44.00 D7250 Surg rem of residual tooth roots $ $65.00 D7510 I&d abscess intraoral-soft tissue $75.00 $ D7960 Frenulectomy-frenectomy/frenotomy $ $65.00 OTHER SERVICES D9110 Palliative (er) tx-dent pain-minor $40.00 $28.00 D9220 Deep Sedation/General Anesthesia first 30 minutes $ $ D9221 Deep Sedation/General Anesthesia - each Add'l 15 minutes $50.00 $61.00 D9241 IV Conscious Sedation, first 30 minutes $ $ D9242 IV Conscious Sedation, each additional 15 minutes $50.00 $61.00 Class III Services are subject to a 6-month waiting period when provided by an Out-of-Network dentist R1

6 The image part with relationship ID rid18 was not found in the file. Principal Exclusions & Limitations Covered Expenses Will Not Include and No Benefits Will Be Payable: 1. In the first twelve months that a person is insured if the person is a Late Entrant; except for exams, cleanings and fluoride application. The benefits are limited to procedures numbered 0120, 0140, 0150, 0180, 1110, 1120, 1206 and For any treatment which is for cosmetic purposes, or to correct congenital malformations, other than medically necessary treatment of congenital cleft in the lip or palate, or both. 3. To replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed bridge within five years of the date of the last placement of these items. But if a replacement is required because of an accidental bodily injury sustained while the Insured is covered under this section, it will be a Covered Expense. 4. For initial placement of any prosthetic appliance or fixed bridge unless such placement is needed because of the extraction of one or more natural teeth while the Insured is covered under this section. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth. 5. For any procedure begun before the Insured was covered under this section. 6. For any procedure begun after the Insured s insurance under this section terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the Insured s insurance under this section terminates. 7. To replace lost or stolen appliances. 8. For appliances, restorations, or procedures to: a. alter vertical dimensions; b. restore or maintain occlusion c. splint or replace tooth structure lost as a result of abrasion or attrition; or d. treat disturbances of the temporomandibular joint. 9. For any procedure which is not shown on the List of Dental Procedures. 10. For education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control. 16. For charges for which the Insured is not liable or which would not have been made had no insurance been in force. 17. For services which are not recommended by a dentist or which are not required for necessary care and treatment. 18. Because of ware or any act of war, declared or not. 19. To an Insured if payment is not legal where the Insured is living when expenses are incurred. 20. Any services related to: equilibration; bite registration or bit analysis. 21. Crowns for the purpose of periodontal splinting. 22. Charges for: any implants; precision or semi-precision attachments and any endodontic treatment associated with it; other customized attachments, unless specifically listed in this booklet. 23. For endodontic treatment of the same tooth within a three (3) year period. 24. For root canal retreatment when it has not been demonstrated that unusual morphological or pathological conditions exist and when performed by a non-endodontic specialist. 25. For more than one filling for each tooth surface in a 24 month period. 26. For non-surgical periodontal treatment more than once in two (2) year period. 27. For surgical periodontal treatment more than once in a three (3) year period. 28. For crown build-ups when less than three (3) of the five (5) tooth surfaces are destroyed. 29. For crown build-ups (pin, bonded, or post and core) more than once in a five (5) year period. Managed by 11. For the completion of claim forms. 12. For sealants which are: a. not applied to a permanent molar; b. applied after attaining age 17; c. applied to a molar more than once. 13. Gingival flap procedure, including root planning (procedure numbers 4240, 4241, 4340 and 4341) unless the presence of periodontal disease is confirmed by both x-rays and pocket depth summaries of each tooth involved. 14. Because of an injury arising out of, or in the course of, work for wage or profit. 15. By an Insured because of a sickness, injury or condition for which he or she is eligible for benefits under Worker s Compensation or similar laws R East East Highland Highland Avenue, Avenue, Ste. 250 Phoenix, Suite Arizona Phoenix, Arizona (FAX) (FAX) Rated A+ (Superior) by A.M. Best and Rated A (Excellent) by Weiss Rating, Inc.

7 PPO PROVIDER DIRECTORY GENERAL DENTISTS BISMARCK Timothy Anderson, DDS (701) Missouri River Dental 1401 Skyline Blvd ste 210 Kevin Bjork, DDS (701) Bjork Dental 1929 N. Washington St, Suite 00 Alexa Carlson, DMD (701) Bridging the Dental Gap 1223 S 12th St #1 Casey Carlson, DDS (701) Casey Carlson, DDS (701) Anthony Frank, DDS (701) A Lifetime of Smiles 1004 S. 7th Street Kevin Gilchrist, DDS (701) Dr. Kevin Gilchrist 1929 N Washington St. Richard Hieb, DDS (701) Richard Hieb, DDS (701) Derik Hoener, DDS (701) A Lifetime of Smiles 1004 S. 7th Street Leslie Hollevoet, DDS (701) Leslie Hollevoet, DDS (701) Bradley King, DDS (701) Bradley King, DDS (701) Dean Knudsen, DDS (701) Knudsen Dean 714 South 2nd Street Joanne Luger, DDS (701) Bridging the Dental Gap 1223 S 12th St #1 Sarah Mertz, DDS (701) Bridging the Dental Gap 1223 S 12th St #1 Steve Midstokke, DDS (701) Midstokke Family Dentistry 2940 N. 19th Street #3 Kevin Munns, DDS (701) Kevin Munns, DDS (701) Riley Parker, DMD (701) Riley Parker, DMD (701) John Persson, DDS (701) John Persson, DDS (701) William Quinn, DDS (701) William Quinn, DDS (701) Andrew Schmid, DDS (701) Bjork Dental 1929 N. Washington St, Suite 00 Sidney Schmidt, DDS (701) Sidney Schmidt, DDS (701) Kathryn Schneibel, DDS (701) Kathryn Schneibel, DDS (701) Chris Spies, DDS (701) Chris Spies, DDS (701) Daniel Van Buskirk, DDS (701) Bismarck Dentistry 4401 Coleman St #104 Nicholas Wangler, DDS (701) The Dental Suite PC 3255 Greensboro Drive, #101 Ashley Wangler, DDS (701) The Dental Suite PC 3255 Greensboro Drive, #101 Thomas York, DDS (701) York Thomas 1102 S. Washington BOWMAN Patrick Kelly, DDS (701) Prairie Dental 608 Highway 12 W Jennifer Sarsland, DDS (701) Prairie Dental 608 Highway 12 W COOPERSTOWN Arlo Neumiller, DDS (701) Agassiz 1200 Roberts Avenue NE CROSBY Page 1 September 28, 2017

8 PPO PROVIDER DIRECTORY Edward Maisey, DDS (701) Edward Maisey DDS 112 1st St. NW Willam Maisey, DDS (701) William Maisey, DDS 112 1st St. NW ENDERLIN Ryan Dahl, DDS (701) Ryan Dahl, DDS PC 213 4th Avenue FARGO Tanya Bonicelli, DDS (701) Dr B Dentistry PC th Street SW Joshua Breding, DDS (701) Joanna Brekhus, DDS (701) Jonathan Bultema, DDS (701) James Colbert, DDS (701) Fargo Family Dentistry TH ST S Jonathan Dahl, DDS (701) Jonathan P Dahl DDS DS PC rd St S Nomuhle Dube, DDS (701) Fargo Moorhead Dental & Dentures th Avenue South, Suite 10 Matthew Eaton, DDS (701) Valley Dental 1338 Gateway Dr Christopher Eriksson, DDS (701) Urban Dental Health PLLC 1815 University Dr. S #3 Courtney Gieseke, DDS (701) Jonathan P Dahl, DDS rd St. S. Suite 1A Krista Johnson, DMD (701) Aspen Dental Fargo th Street S Suite 108 James F Johnson, DDS (701) Johnson DDS, James F th Street SW Robert Mack, DDS (701) Jonathan P Dahl DDS DS PC rd St S Emily Miller, DMD (701) Aspen Dental Fargo th Street S Suite 108 Edward Nam, DDS (701) Fargo Moorhead Dental & Dentures th Avenue South, Suite 10 Lynne M Olson Rommesmo, DDS (701) Lynn M Olson Rommesmo th Avenue N James Podrebarac, DDS (701) Brian Quamme, DDS (701) Fargo Moorhead Dental & Dentures th Avenue South, Suite 10 Lindsay Rogers, DDS (701) Courtney Rud, DDS (701) Svetlana Sampson, DDS (701) About Smiles Dental LLC rd Ave S Meghan Smith, DDS (701) Valley Dental 1338 Gateway Dr Samuel Sticka, DDS (701) Devin Walker, DDS (701) Fargo Moorhead Dental & Dentures th Avenue South, Suite 10 Devin Walker, DDS (701) About Smiles Dental LLC rd Ave S Andrea Wilson, DMD (701) GRAFTON David Brant, DDS (701) DBG Dental, Inc 15 East 7th Street Boone Brewer, DDS (701) Boone T Brewer DDS PLLC 17 East 7th Street Neil Daby, DMD (701) Daby Neil 15 E. 7th St. James Duerre, DDS (701) Duerre James 17 E. 7th St. Joseph Kern, DDS (701) Kern Family Dentistry 21 West 5th Street GRAND FORKS Jerome Austriaco, DDS (701) Aspen Dental 3300 South 32nd Avenue Suite 103 John Baden, DDS (701) John J Baden, DDS 2512 South Washington Steven Erlandson, DDS (701) Steven Erlandson 2401 S. Washington St. #D Rory Manke, DDS (701) Manke Family Dentistry 2401 S Washington St #B Lauren Manke, DDS (701) Manke Family Dentistry 2401 S Washington St #B Brian Nord, DDS (701) Nord Dentistry TH AVE S Brian Parr, DDS (701) Brian C. Parr, DDS Page 2 September 28, 2017

9 PPO PROVIDER DIRECTORY 1165 B S. Columbia Rd. Puja Patel, DDS (701) Aspen Dental 3300 South 32nd Avenue Suite 103 Dan Schefter, DDS (701) Schefter DDS, Dan nd Avenue South Kathryn Schneibel, DMD (701) Aspen Dental 3300 South 32nd Avenue Suite 103 Duc V Tran, DDS (701) D Tran DDS PC 600 DeMers Avenue Amanda Vesterso, DDS (701) Riverside Dental 1165 S Columbia Rd #B HANKINSON Mark Schaffer, DDS (701) Hankinson Dental 333 Main Avenue HARVEY Marlin Meharry, DDS (701) Marlin G Meharry 317 East Brewster Street LISBON Ryan Dahl, DDS (701) Ryan Dahl DDS PC 11 11th Ave W Ryan Nelson, DDS (701) Lisbon Smiles 420 Main St MANDAN Leah Brady, DDS (701) Ideal Image Dentistry 600 E. Main Sreet, Suite 2 Casey Carlson, DDS (701) Nicole Duckwitz, DDS (701) rd Avenue NM John Grunseth, DDS (701) rd Avenue NM Richard Hieb, DDS (701) Leslie Hollevoet, DDS (701) Bradley King, DDS (701) Michael Maier, DDS (701) rd Avenue NM Anthony Malaktaris, DDS (701) rd Avenue NM Kevin Munns, DDS (701) Riley Parker, DMD (701) John Persson, DDS (701) William Quinn, DDS (701) Sidney Schmidt, DDS (701) Kathryn Schneibel, DDS (701) Chris Spies, DDS (701) MAYVILLE MINOT Robert Lauff, DDS (701) Goose River Dental 37 1/2 Main Street E Jerome Austriaco, DDS (701) Aspen Dental 3451 S Broadway #B Whitney Bruins, DDS (701) Northland Community Health Center Rolette 15 2nd Ave SW, #110 Nathan Burbach, DDS (701) Northland Community Health Center Rolette 15 2nd Ave SW, #110 Stanley Hirst, DDS (701) Stanley Hirst 1839 S Broadway Bethany Jensen, DDS (701) Stanley Hirst 1839 S Broadway Robert Kifer, DDS (701) Northland Community Health Center Rolette 15 2nd Ave SW, #110 Bardha Krasniqi, DMD (701) Northland Community Health Center Rolette 15 2nd Ave SW, #110 Puja Patel, DDS (701) Aspen Dental 3451 S Broadway #B Kathryn Schneibel, DMD (701) Aspen Dental 3451 S Broadway #B ROLETTE TIOGA Robert Kifer, DDS (701) Northland Community Health Center Rolette 401 2nd Avenue David Carlson, DDS (701) David Carlson DDS 111 Main TURTLE LAKE Whitney Bruins, DDS (701) Northland Community Health Center Turtle Lake Page 3 September 28, 2017

10 PPO PROVIDER DIRECTORY 416 Kundert Street Nathan Burbach, DDS (701) Northland Community Health Center Turtle Lake 416 Kundert Street Bardha Krasniqi, DMD (701) Northland Community Health Center Turtle Lake 416 Kundert Street VALLEY CITY Lynn Odne, DDS (701) Odne Lynne 915 2nd Street SW WAHPETON Susan Swanson, DDS (701) N. D. College-Hygiene Services 800 6th St. N. Mark Wasemiller, DDS (701) Wasemiller Mark th St. S. WATTFORD CITY Edward Maisey, DDS (701) Edward Maisey DDS 109 5th St. SW WILLISTON Scott Ellis, DDS (701) Ellis Scott 501 Main Street John Hamilton, DDS (701) Hamilton John nd Avenue West Willam Maisey, DDS (701) Edward Maisey DDS 708 Main Edward Maisey, DDS (701) Edward Maisey DDS 708 Main ENDODONTISTS FARGO Jerry Cook, DMD (701) Cook Endodontics 4710 Amber Valley Pkwy S Michael D Peterson, DMD (701) Cook Endodontics 4710 Amber Valley Pkwy S Kelli Swenson, DDS (701) Cook Endodontics 4710 Amber Valley Pkwy S Ross Yost, DDS (701) Cook Endodontics 4710 Amber Valley Pkwy S GRAND FORKS Jerry Cook, DMD (701) Cook & Swenson Endodontics 3425 S Washington St, Ste B Michael D Peterson, DMD (701) Cook & Swenson Endodontics 3425 S Washington St, Ste B Kelli Swenson, DDS (701) Cook & Swenson Endodontics 3425 S Washington St, Ste B Ross Yost, DDS (701) Cook & Swenson Endodontics 3425 S Washington St, Ste B ORAL SURGEONS BISMARCK Mansureh Iravani, DDS (701) Oral Surgery Center 3117 North 14th St. FARGO Michael Noffze, DDS (701) Oral Maxillofacial Associates 300 Main Ave #201 GRAND FORKS Troy Petersen, DMD (701) Valley Oral & Facial Surgery 1165 South Columbia Road Marcus Tanabe, DDS (701) Valley Oral & Facial Surgery 1165 South Columbia Road JAMESTOWN Michael Noffze, DDS (701) Oral Maxillofacial Associates th St SE WEST FARGO Troy Petersen, DMD (701) Valley Oral & Facial Surgery 3187 Bluestem Dr, Ste. 4 Rudy Schneider, DMD (701) Valley Oral & Facial Surgery 3187 Bluestem Dr, Ste. 4 Marcus Tanabe, DDS (701) Valley Oral & Facial Surgery 3187 Bluestem Dr, Ste. 4 PEDODONTISTS BISMARCK Stanislaus Dyda, DDS (701) Stanislaus Dyda, DDS (701) Travis Giese, DDS (701) Travis Giese, DDS (701) MANDAN Stanislaus Dyda, DDS (701) Travis Giese, DDS (701) Page 4 September 28, 2017

11 PPO PROVIDER DIRECTORY PROSTHODONTISTS WILLISTON Loye Ashton, DDS (701) Ashton Loye 120 Main Street GENERAL DENTISTS ALBERTVILLE Adam Erickson, DDS (763) White Smiles Family Dentistry 6563 Laketowne Place #A BARNESVILLE Jonathan Dahl, DDS (218) Jonathan P Dahl, DDS 102 Front Street Courtney Gieseke, DDS (218) Jonathan P Dahl, DDS 102 Front Street Stacy Gould Seaborn, DDS (218) Jonathan P Dahl, DDS 102 Front Street Robert Mack, DDS (218) Jonathan P Dahl, DDS 102 Front Street CHOKIO Timothy Carlson, DDS (320) Chokio Dental 118 Main St. DETROIT LAKES Thomas Fritz, DDS (218) Washington Ave. Elizabeth McCauley, DDS (218) Washington Ave. Carolyn Zunich, DDS (218) Washington Ave. DETROIT LAKES Kristine Riewer, DDS (218) Lakeridge Dental Partners 701 Highway 10 East Donald Steinmetz, DDS (218) Lakeridge Dental Partners 701 Highway 10 East HALSTAD Joyce Hollinshead, DDS (218) Dr Joy's Dental Clinic 132 3rd St W HENNING Michael Berglund, DDS (218) MICHAEL BERGLUND DDS 404 Douglas Ave. MENAHGA CITY Charles Restemayer, DDS (218) MOORHEAD Restemayer Charles 16 Birch Ave. Joanna Brekhus, DDS (218) North 11th Street #106B William Savage, DDS (218) North 11th Street #106B Andrea Wilson, DMD (218) North 11th Street #106B NEW YORK MILLS Rachel Grieger, DDS (218) Grieger Rachel 206 Walker Ave. N. PARK RAPIDS Guy Reich, DDS (218) Reich Guy 314 Pleasant Ave. S. Christina Robin, DDS (218) Northwoods Dental Clinic 120 Main Ave. N. PERHAM SALOL Michael Hamann, DDS (218) Hamann Michael 200 1st Ave. S. Bruce Falk, DDS (218) Falk Dental CO Rd. 133 WADENA Ryan Anderson, DDS (218) Woodland Dental Inc. 206 First St. SE Wayne Howard, DDS (218) Howard Wayne 122 Colfax Avenue SW James Matthiae, DDS (218) James Matthiae, DDS 206 1st St. SE Christopher OKane, DDS (218) Christopher O'Kane DDS 124 Colfax Ave. SW WHEATON Michael Marchetti, DDS (320) Marchetti Michael 1511 Broadway ORAL SURGEONS ALEXANDRIA Robert Keck, DDS (320) Centrasota Oral & Maxillofacial Surgeons nd Ave. E. Ste. 103 Harold Machesky, DDS (320) Centrasota Oral & Maxillofacial Surgeons nd Ave. E. Ste. 103 Page 5 September 28, 2017

12 PPO PROVIDER DIRECTORY Gustavo Pena-Velasco, DDS (320) Centrasota Oral & Maxillofacial Surgeons nd Ave. E. Ste. 103 Donald Primley, DDS (320) Centrasota Oral & Maxillofacial Surgeons nd Ave. E. Ste. 103 Eric Stine, DDS (320) Centrasota Oral & Maxillofacial Surgeons nd Ave. E. Ste. 103 Roderick VanSurksum, DDS (320) Centrasota Oral & Maxillofacial Surgeons nd Ave. E. Ste. 103 SAINT CLOUD Harold Machesky, DDS (320) Machesky Harold 3950 Vetrans Drive #100 WADENA Michael Zachar, DDS (218) Woodland Dental Inc. 206 First St. SE Page 6 September 28, 2017

13 TOTAL DENTAL ADMINISTRATORS, INC. PROVIDER NOMINATION FORM I would like to nominate my dentist for inclusion in the Total Dental Administrators Elite Choice Dental plan North Dakota Provider Network. I understand that TDA retains final authority for approving membership and inclusion in the Provider Network. I also understand that TDA may use my name when contacting the dental provider and inform him/her of my desire for him/her to join the TDA Provider Network. Please note: This form does not serve as an enrollment form dental benefits. YOUR INFORMATION Date: Patient s Name: Employer: Telephone: DENTIST INFORMAITON Name: Address: Telephone: Specialty: If you have any questions about participating in the TDA Elite Choice dental plan North Dakota Provider Network, please do not hesitate to contact TDA toll free at (888) Please submit this form to: Total Dental Administrators, Inc. Attention: Provider Relations 2111 E. Highland Avenue, Suite 250 Phoenix, Arizona Fax: (602) or CustomerService@TotalDentalAdmin.com For more information about Total Dental Administrators, Inc., please visit our Web site at or call (888)