How does a dental provider terminate enrollment as a Denti-Cal provider?
A Medi-Cal provider number can be terminated by the submission of a Medi-Cal Supplemental Changes (form DHCS 6209) requesting to deactivate a provider number under the Miscellaneous section or by submitting a letter in writing with his\her request to deactivate\terminate their provider number. The provider(s) must sign the letter and include a legible, valid copy of the driver’s license or state-issued identification card number.
