Create a Mentor Profile

The following information will be used to build and display your mentor profile on wsda.org. Please provide contact information to which you would like to receive communications from potential mentees.

First Name

Last Name

DDS or DMD?

ADA Number

Personal Phone Number

This information will be displayed on your mentor profile. Please provide a phone number at which mentees will most easily reach you.

Personal Email Address

This information will be displayed on your mentor profile. Please provide an email address at which mentees will most easily reach you.

LinkedIn Profile

How do you prefer to be contacted? (Select all that apply.)

Phone Call
Text
Email
LinkedIn Message

Gender

Male
Female
Non-Binary/Non-Conforming

Specialty

Undergraduate School

Dental School

Dental School Class Year

Residency/Specialty/Graduate Program (If Applicable)

Primary Practice Name

Primary Practice City

Primary Practice Website

Practice/Provider Type

Owner – Private Practice
Owner – Group Practice
Associate/Employee – Private Practice
Associate/Employee – Group Practice
Independent Contractor
Faculty
Retired

Military Branch (If Applicable)

Professional Affiliations

Brief Personal Bio

Please introduce yourself to potential mentees. Some topics to consider including are home town, years in practice, languages spoken, preferred pronouns, etc. Consider phrasing years in practice as "I've been practicing since XXXX" to avoid needing to update your years in practice each year.

Why is being a mentor important to you?

What is your favorite dental instrument or procedure?

What is something most people don't know about you?

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Build Your Mentor Profile

General Information

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