Create - New Customer

New Customer Setup

This form will establish a new account and request payment terms with Benco Dental.

Account Information

Account Name

Owner's Name

Address 1

Address 2

Address 3

City

State

ZIP Code

Billing Address 1

Billing Address 2

Billing Address 3

Billing City

Billing State

Billing ZIP Code

Shipping Address Same As Office Address

Contact Information

Contact Name

Office Phone Number

Office Email Address

License Information

Providing this information will expand the catalog to include products requiring a license.

Doctor's First Name

Doctor's Middle Initial

Doctor's Last Name

Login Information

Username

Password

Please be aware that your current password does not conform to our minimum strength policy. This policy is that a password should be at least 8 characters with at least one letter, number, and symbol.

Confirm Password

MSDSonline Customer License

User agrees that it is a customer of Benco Dental Supply, Co. and that the use of the MSDSonline system shall be limited to use by the customer and its employees. Pursuant to 21 CFR 1910.1200(g)(8), user consents to the supply of Safety Data Sheets (SDS) via electronic means.