South Bismarck (701) 223-1194 North Bismarck (701) 223-8262 Mandan (701) 751-3237

Nominate

2023 Mother’s Day Smile Makeover Giveaway


Nominator's Info:

Name of Nominator:

Phone Number:

Email Address:

Street Address:

City:

State:

Zip/Postal Code:

Nominee Info:

Name of Nominee:

Phone Number:

Email Address:

Street Address:

City:

State:

Zip/Postal Code:

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: