Title Dr Ms Mr Initials Name * First Name Last Name Email * Phone (###) ### #### Profession * HPCNA No * Practice Name * Practice Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Checkbox Dentists and Specialists N$ 2900 Dental Therapists N$ 1900 Oral Hygienists N$ 950 Dental Technicians N$ 950 Thank you!Please make a payment to Bank WindhoekBranch No 483 872 Maerua MallAccount No 8000 664 742
