KRZ Business Accelerator | Las Olas Dentistry Verification Intake

All fields marked with * are required. You can attach a clear photo or a PDF scan of each document. If a file is too large to attach, please reply to the confirmation email with that document instead.

1 Business Information

Legal details of the practice, as they appear on official documents.

Exact legal business name *

Important: this must match the document you upload below. If it differs from "Las Olas Dentistry," enter the exact registered name here.

EIN (Federal Tax ID) *

Official business address *

Pre-filled with the address on file. Please correct it if the official address is different.

Business phone *

Business email *

2 Authorized Representative

The person responsible for the account, typically the owner.

Full legal name *

Role at the practice

3 Upload Documents

Attach the items below. Photos or PDF scans are both fine.

Business proof document * Choose fileEIN letter, business license, incorporation docs, bank statement, or utility bill

Government issued photo ID of the representative * Choose fileDriver's license or passport

Florida dental license (for Local Services Ads) Choose fileActive license for Dr. David Escalante

Professional liability insurance (for Local Services Ads) Choose fileCurrent malpractice insurance certificate

Anything else we should know?

Your information is sent securely to KRZ Business Accelerator and used only to verify the clinic's advertising accounts.
Questions? Just reply to the confirmation email.