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General Information


Date Of Birth *
Marital Status *    Married   Single
Name of Spouse
Gender *   Male   Female
Is your Spouse a Densit *    Yes   No
Is your Spouse a Member of IDA *   Yes   No

Educational Qualification


Practice Information *


General Practice    Oral medicine & Radiology   Pediatric Dentistry   
Prosthodontics    Oral Pathology & Microbiology     Endodonticts  
Periodontics   Oral & Maxillofacial surgery   Orthodontics  
Public Health Dentistry   Other

Affiliation



Designation *


Lecture Asst. professor Professor Dean (or) Professor
Director Dental Surgeon

Office Address



Home Address



Member Photo *



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