Request a Confidential Practice Valuation This helps us understand your practice and goals so we can provide a realistic valuation range and transition options Contact Information Practice Basics Performance snapshot Payer and Services Facility and Lease Technology and Equipment Consent and Disclaimer Blank Form (#5)Δ Full NamePhone NumberEmailBest time to reach youPreferred contact methodPractice City and CountyPractice Type GP Ortho Pedo Endo OS PerioOwnership Structure Solo PartnershipAre you the owner? Yes NoLast 12 months collection- Select -$500–$750kOperatories (Plumbed)Active PatientsLast 12 months adjusted net / take-home- Select -Less than $500k$500–$750kStaff count (front/back)Payer Mix FFS%Payer Mix PPO%Medicaid/Denti-Cal %Top procedures GP Ortho Pedo Endo OS Perio Multi SpecialtyAre fees at/above/below local averages?Facility Lease OwnCurrent rent + lease term remaining + optionsSq ftParking Yes NoCondition Updated Average DatedDigital Sensors Yes NoCBCT Yes NoIntraoral Scanner Yes NoCharting SoftwareMajor equipment age/conditionTimeline- Select -0–6 months6–12 monthsUnsureIdeal Outcome- Select -Sell 100%Partial Buy-InBring associate then sellDSOs consideredConfidentiality Level- Select -High (no staff know)ModerateConfidentiality Level- Select -High (no staff know)Moderate I confirm I’m authorized to share this information and understand this is an estimate, not a formal appraisal. MDBL will keep this confidential and won’t share details without permission.Submit Form