Nominator's Info:
Name of Nominator:
Phone Number:
Email Address:
Street Address:
City:
State:
Zip/Postal Code:
Nominee Info:
Name of Nominee:
Income Range:
1. Please provide a brief explanation of the type of dental work that the nominee needs:
2. Tell us why this person deserves a brand new smile and how it will impact their life:
South Bismarck | 121 E. Front Ave., Bismarck, ND 58504 l Ph (701) 223-1194
North Bismarck | 900 E. Calgary Ave., Bismarck, ND 58503 l Ph (701) 223-8262
Mandan | 2500 Overlook Lane, Mandan, ND 58554 l Ph (701) 751-3237
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