What happened in 2019 for Dentists vs Corporations?

[Cold Front]

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Is it really that easy to leverage debt though? Why don't other people do it?

I was almost refused on the $2M+ commercial loan - not because of my credit, but because of my age (was in my early 30’s at the time). It’s not every day that a $3M mortgage application from a 33 years old comes across a bank underwriter’s desk. That creates a little more scrutiny.

Banks underwrite different loans differently. Commercial loans are for highly tangible assets, because there are businesses doing businesses in the buildings I purchased and built as tenants - and even if I defaulted or ran into other financial issues, the banks would still collect rent from the tenants. So it was low risk to the banks, specially when there are corporate guarantees backing those tenant leases.

Also, it’s very hard to buy a commercial building unless you are a major tenant who would buy the building an owner-occupant. Again, it’s low risk to the banks when you are an owner-occupant than just a hands-off investor.

Also, dentists are (fortunately) considered very good risk for banks, due to them being in a low default rate industry. So that too helped too.

Finally, none of my commercial investments couldn’t have happened without collaterals (my offices practice) - they were leveraged. It was ok with me - because if I couldn’t handle the building mortgages (which were lower than what I paid in rent to my previous landlord), then my offices would be destined to fail too. Also, I had to get a special life insurance ($300 a year) just for banks to be more protected. There were other little rules that I can’t get into all here - but you get the idea.


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[ToothJockey]

I was almost refused on the $2M+ commercial loan - not because of my credit, but because of my age (was in my early 30’s at the time). It’s not every day that a $3M mortgage application from a 33 years old comes across a bank underwriter’s desk. That creates a little more scrutiny.

Banks underwrite different loans differently. Commercial loans are for highly tangible assets, because there are businesses doing businesses in the buildings I purchased and built as tenants - and even if I defaulted or ran into other financial issues, the banks would still collect rent from the tenants. So it was low risk to the banks, specially when there are corporate guarantees backing those tenant leases.

Also, it’s very hard to buy a commercial building unless you are a major tenant who would buy the building an owner-occupant. Again, it’s low risk to the banks when you are an owner-occupant than just a hands-off investor.

Also, dentists are (fortunately) considered very good risk for banks, due to them being in a low default rate industry. So that too helped too.

Finally, none of my commercial investments couldn’t have happened without collaterals (my offices practice) - they were leveraged. It was ok with me - because if I couldn’t handle the building mortgages (which were lower than what I paid in rent to my previous landlord), then my offices would be destined to fail too. Also, I had to get a special life insurance ($300 a year) just for banks to be more protected. There were other little rules that I can’t get into all here - but you get the idea.


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Yeah I think the fact that you already had a high income from your practice definitely helped.

I'm guessing that the properties will be enough to fund your retirement. Has that been your major focus, building up a real estate portfolio for income during retirement? as opposed to investing in stocks and bonds etc.

I've been reading FIRE forums, white coat investor and the reddit forums, everyone seems to have a different strategy to become financially independent.

 

[Cold Front]

Yeah I think the fact that you already had a high income from your practice definitely helped.

I'm guessing that the properties will be enough to fund your retirement. Has that been your major focus, building up a real estate portfolio for income during retirement? as opposed to investing in stocks and bonds etc.

I've been reading FIRE forums, white coat investor and the reddit forums, everyone seems to have a different strategy to become financially independent.

For me, yes - everything I invest in and almost get up every morning for is for retirement. Investing in stocks comes with management fees and a lot of deferral rules to avoid penalties and taxes. Real estate is more tangible and you have more control over it if you go about it the right way.

I could not do the FIRE strategy, I wouldn’t not last a minute or couldn’t talk myself into living that low below my means. I heard good things about white cost investor but never read them. I just focused on my city and where to build/open practices, then invested vertically into real estate from there.

You would see me telling predents to be careful with high student loans, because I have seen so many “average dentist” in my career - many as friends, formers associates and so on. Majority of dentists love to just chill and take life by the month. Their horizon is not so much in retirement, but more in their next break from work/vacation and just going through other personal obligations (family life, poker nights, gym, and so on). I had dentist friends that got caught up with bitcoin and cryptocurrencies, and lost a lot of money. I had friends who opened practices and close them within a year. Others just decided to specialize with the hope of making more money - and not for the love of the specialty.

So planning is the key to everything, in doing more of something you are passionate about.


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[monkeykey]

You should treat yourself to a nice vacation next Christmas.

I’m 40 now, and 48 sounds like right about the age I should be debt free too. This will be a shocker to some readers, but my debt once reached $7M. That’s not a typo, but it was mostly in commercial real estate loans - I didn’t rush into paying off my student loans after I graduated from DS. I still carry about $4M in loans today, kind of scary at first glance, but very secured with class A tenants with long term leases. I don’t know what I will do when I’m debt free, but if it was today, I would have rewarded myself with something to mark the occasion/milestone. Maybe a nice watch, a river cruise in Europe, a dinner date with the wife at a 3 star Michelin restaurant, or something similar.



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Do banks allow you to take out these large rental property loans at 3-4% interest rates similar to that of a mortgage with the property seen as collateral for the loan? What kind of interest rates do you think most people get for these loans assuming they have excellent credit?

 

[Cold Front]

Do banks allow you to take out these large rental property loans at 3-4% interest rates similar to that of a mortgage with the property seen as collateral for the loan? What kind of interest rates do you think most people get for these loans assuming they have excellent credit?

My commercial loans are at 4.5%. Today, rates are closer to 6-7%.


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[cluelessdr]

do you guys see more corporate taking over rural areas? i hear all the time "go rural because of saturation" but what if corporate takes over, arent we screwed then?

 

[ToothJockey]

For me, yes - everything I invest in and almost get up every morning for is for retirement. Investing in stocks comes with management fees and a lot of deferral rules to avoid penalties and taxes. Real estate is more tangible and you have more control over it if you go about it the right way.

I could not do the FIRE strategy, I wouldn’t not last a minute or couldn’t talk myself into living that low below my means. I heard good things about white cost investor but never read them. I just focused on my city and where to build/open practices, then invested vertically into real estate from there.

You would see me telling predents to be careful with high student loans, because I have seen so many “average dentist” in my career - many as friends, formers associates and so on. Majority of dentists love to just chill and take life by the month. Their horizon is not so much in retirement, but more in their next break from work/vacation and just going through other personal obligations (family life, poker nights, gym, and so on). I had dentist friends that got caught up with bitcoin and cryptocurrencies, and lost a lot of money. I had friends who opened practices and close them within a year. Others just decided to specialize with the hope of making more money - and not for the love of the specialty.

So planning is the key to everything, in doing more of something you are passionate about.


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Preach man, there’s a reason the average dentist retires at 70 (seems late compared to most professions). Dentists are either pretty bad with money or love their jobs so much they never retire. I feel like for the grads with high loans, it is going to be the former.

I personally don’t care to retire early, I feel like I would actually enjoy dentistry. But it would nice to be financially independent in my 40’s so that I can work for fun rather than to put food on the table.


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[ToothJockey]

do you guys see more corporate taking over rural areas? i hear all the time "go rural because of saturation" but what if corporate takes over, arent we screwed then?

The reason rural is underserved is because few dentists want to work in the boonies. Even if corporate goes rural, they need to be able to find dentists willing to work in those areas, until then you should be fine.


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[2TH MVR]

Preach man, there’s a reason the average dentist retires at 70 (seems late compared to most professions). Dentists are either pretty bad with money or love their jobs so much they never retire. I feel like for the grads with high loans, it is going to be the former.

I personally don’t care to retire early, I feel like I would actually enjoy dentistry. But it would nice to be financially independent in my 40’s so that I can work for fun rather than to put food on the table.


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It's pretty difficult for a young person entering a field to have predetermined ideas on future retirement. Everyone will make future financial mistakes that will impact your retirement regardless how smart or prepared you are. Nobody has a crystal ball. Life happens and when it does ... there will be present and future financial implications. That is reality. Raising a family is expensive. Out of pocket healthcare for those unexpected medical emergencies is expensive. Daughters getting married is expensive. Going on nice vacations is expensive. If you've done relatively well in life. Lived life to it's fullest. Nice home. Nice cars. Etc. Etc. Well ..... you want to keep that same lifestyle. I know I do. So many of us choose to continue to work. Work also provides workplace stimuli outside of just getting a paycheck. But I get to work on MY TERMS. Sold my practices and took a Corp job. My stress level has decreased 100 fold. My life is simpler. No stress. Simple work atmosphere adds up to working for as long as I want.

But yes. Decisions predents make today will seriously impact their future earnings and investments. Passion in the present moment (I want to be a dentist at all costs) will not be the same 20-30 yrs later when the reality of excessive debt repayment sets in.

 

[ToothJockey]

It's pretty difficult for a young person entering a field to have predetermined ideas on future retirement. Everyone will make future financial mistakes that will impact your retirement regardless how smart or prepared you are. Nobody has a crystal ball. Life happens and when it does ... there will be present and future financial implications. That is reality. Raising a family is expensive. Out of pocket healthcare for those unexpected medical emergencies is expensive. Daughters getting married is expensive. Going on nice vacations is expensive. If you've done relatively well in life. Lived life to it's fullest. Nice home. Nice cars. Etc. Etc. Well ..... you want to keep that same lifestyle. I know I do. So many of us choose to continue to work. Work also provides workplace stimuli outside of just getting a paycheck. But I get to work on MY TERMS. Sold my practices and took a Corp job. My stress level has decreased 100 fold. My life is simpler. No stress. Simple work atmosphere adds up to working for as long as I want.

But yes. Decisions predents make today will seriously impact their future earnings and investments. Passion in the present moment (I want to be a dentist at all costs) will not be the same 20-30 yrs later when the reality of excessive debt repayment sets in.

Right, there's nothing wrong with working until you're 70 as long as you actually enjoy it. It's different if you're working at 70 because you still have to pay off a mortgage, or you're still living paycheck to paycheck. Guess which group a lot of future grads are gonna belong to...

You cannot control unexpected expenses which arise because life happens. You can definitely control not spending 600k for a degree however. And if you're gonna be going the dental route anyways, you should have a financial plan laid out. There's absolutely no reason to wing it.

 

[MilknCheerios]

Almost all millionaires had to get into debt at some point, whether it was starting a business, investing, or school. Even look at the big corporations in dentistry, almost all of them have millions of dollars of debt, everytme they purchase a new practice they probably go more in debt.

Is it really that easy to leverage debt though? Why don't other people do it?

First off, I'm not a dentist nor a businessman, but this so called rise of corporate dentistry sounds similar to the prevalence of chain pharmacies. So, the thing about corporate-run pharmacies is that they are massively funded by investors and banks willing to loan out large sums of money to the chain pharmacy because they have deep credit lines and historically provide great stock dividends. Well, the chain pharmacy will use this money to out compete or, if needed, buy out its main competitors, independent, family owned pharmacies.

If you compete against (any) corporate giant, be aware that they have deep wallets and are not afraid to hemorrhage money in the short term to put stress on you and your business, take away customers, ultimately with the hope that you will pack up and go. Once the competition is gone, they can make more money in the long term.

Getting back to your question, those corporations are in debt and they don't care because they will just borrow more money or sell more of its stock to put you out of business. Other people can not go into such debt because of their credit limits and because it's extremely risky to borrow more money than can be paid back. Now, obviously, I could be wrong about all this, but it makes a bit of sense, no?

 

[ToothJockey]

First off, I'm not a dentist nor a businessman, but this so called rise of corporate dentistry sounds similar to the prevalence of chain pharmacies. So, the thing about corporate-run pharmacies is that they are massively funded by investors and banks willing to loan out large sums of money to the chain pharmacy because they have deep credit lines and historically provide great stock dividends. Well, the chain pharmacy will use this money to out compete or, if needed, buy out its main competitors, independent, family owned pharmacies.

If you compete against (any) corporate giant, be aware that they have deep wallets and are not afraid to hemorrhage money in the short term to put stress on you and your business, take away customers, ultimately with the hope that you will pack up and go. Once the competition is gone, they can make more money in the long term.

Getting back to your question, those corporations are in debt and they don't care because they will just borrow more money or sell more of its stock to put you out of business. Other people can not go into such debt because of their credit limits and because it's extremely risky to borrow more money than can be paid back. Now, obviously, I could be wrong about all this, but it makes a bit of sense, no?

Yeah it definitely makes sense. That's probably why the biggest corps with the most private equity funding will end up buying out all smaller corps, and in the end everything will be consolidated to 3-4 major corporations. I just wonder if in dentistry corporate will take as large of a market share as in pharmacy. In medicine, corps have taken a huge market share, but private practice is still thriving. I wonder what the balance in dentistry will be like.

 

[2TH MVR]

Yeah it definitely makes sense. That's probably why the biggest corps with the most private equity funding will end up buying out all smaller corps, and in the end everything will be consolidated to 3-4 major corporations. I just wonder if in dentistry corporate will take as large of a market share as in pharmacy. In medicine, corps have taken a huge market share, but private practice is still thriving. I wonder what the balance in dentistry will be like.

Agreed. I've said this many times. Over time .... the biggest dental Corp players will eventually buy out or squeeze out the competition. Look at the major car manufacturers. Everyone is merging. FCA and Peugeot are consolidating into PSA. VW group. Platform sharing: Toyota, Subaru, BMW.
The Corp I work for has offices in Arizona, Nevada, California, Texas, Alabama and possibly a few other states. They are steadily growing. Acquiring many pedo type practices along with other specialties. I don't see how these smaller dental Corps have a chance.

As for medicine. At least in Arizona .... the major hospital players are expanding into smaller, retail oriented offices. Tons of them. Kind of like Heartland Dental. They give you the impression that they are a private practice, but they are really a Corp entity.

Everything is Corp. That's the reality. And of course .... we as consumers wanted this. We bought into this.

 

[ToothJockey]

Agreed. I've said this many times. Over time .... the biggest dental Corp players will eventually buy out or squeeze out the competition. Look at the major car manufacturers. Everyone is merging. FCA and Peugeot are consolidating into PSA. VW group. Platform sharing: Toyota, Subaru, BMW.
The Corp I work for has offices in Arizona, Nevada, California, Texas, Alabama and possibly a few other states. They are steadily growing. Acquiring many pedo type practices along with other specialties. I don't see how these smaller dental Corps have a chance.

As for medicine. At least in Arizona .... the major hospital players are expanding into smaller, retail oriented offices. Tons of them. Kind of like Heartland Dental. They give you the impression that they are a private practice, but they are really a Corp entity.

Everything is Corp. That's the reality. And of course .... we as consumers wanted this. We bought into this.

I think corporate takeover will be slower in dentistry than pharm or medicine. The main reason is because most people (me) still go into dentistry to eventually get into ownership/partnership. The % of dentists that want to be associates for life is pretty low I would presume.

Hear me out, Growth of corp is really high right now, because most dentists that work for corp today are either fresh out of school gaining some experience before ownership, or they are at the end of their careers and sold their practice to a DSO. This demographic will always exist and will always work for corps, however for corps to continue growing towards a 50%+ market share, they will have to attract mid career dentists at the peak of their earning potential working for them. You think Cold Front or TanMan are gonna sell their profitable practices and join a corp so they can make 1/5 of what they make now? Naaaa. The reality is turnover at a corp is still pretty high, they have trouble retaining docs for the duration of their careers. I think their exponential growth will begin to slow down...but that's just my uneducated guess

But I agree overall, corporate will take over dentistry at some point in the future, the forces are too large for any single dentist to fight. I just hope this takeover occurs after I'm already 6 feet under 🤣

 

[Cold Front]

Corporations will recruit more new grads every year, while buying practices from older/retiring dentists. So far this is the path that is the most cost effective than a merger or large scale acquisitions. It’s a long game for the corporations - and I think 2040 will be the decade where majority of offices will be DSO’s. Few of us on these boards would have retired by then, and almost all pre-dents today would have adjusted to the new realities at that point.


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[ToothJockey]

Corporations will recruit more new grads every year, while buying practices from older/retiring dentists. So far this is the path that is the most cost effective than a merger or large scale acquisitions. It’s a long game for the corporations - and I think 2040 will be the decade where majority of offices will be DSO’s. Few of us on these boards would have retired by then, and almost all pre-dents today would have adjusted to the new realities at that point.


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Definitely possible. Regardless of what happens with corps, entrepreneurial minded dentists should be on a FI/RE plan. No need to retire, just be financially secure (no debt, high NW). This entire country is gonna be very different by 2040, not just dentistry. A lot of jobs will be lost due to AI (trucker, uber, many jobs in finance etc.), the economy could get bad. It will be key to have diverse income sources, because who knows what the dental economy will look like. It's possible both corp and private practice go downhill. Dentists are nothing without patients.

 

[charlestweed]

Corporations will recruit more new grads every year, while buying practices from older/retiring dentists. So far this is the path that is the most cost effective than a merger or large scale acquisitions. It’s a long game for the corporations - and I think 2040 will be the decade where majority of offices will be DSO’s. Few of us on these boards would have retired by then, and almost all pre-dents today would have adjusted to the new realities at that point.


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If your prediction is correct, then the dentists who have their own practices should do very well in the future because there will be less competition among the private practice owners. I don't understand why dentist owners are concerned about the expansion of corp offices when the corp offices target the type of patients (low income, medicaid, HMO), whom most of them don't want to treat anyway. Dentists should be more concerned about the openings of new private offices near theirs. If more dentists work for the corps and fewer of them set up their own offices, the dentists, who have their own offices, should be able to attract more "rich" patients, who have good PPO plans and cash.

More openings of corp offices means more job opportunities for dentists, especially the ones who don't want to take risk to start a practice.

And the dentists, who manage to do well in oversaturated markets like NYC and CA, will continue to do well despite the openings of new corp offices in their areas.

 

[2TH MVR]

I don't understand why dentist owners are concerned about the expansion of corp offices when the corp offices target the type of patients (low income, medicaid, HMO), whom most of them don't want to treat anyway.

I live in a pretty affluent area in N Scottsdale. Agree that you don't see many Corps in this area, but there are a few popping up in my area. They are marketing to affluent patients.

 

[charlestweed]

I live in a pretty affluent area in N Scottsdale. Agree that you don't see many Corps in this area, but there are a few popping up in my area. They are marketing to affluent patients.

Affluent people are not going to put up with the long wait time, rude assistants, and clueless receptionists at the call centers. They are not going to see a dentist at corp who recommends 10 cavity fillings. And when then they come back to get those fillings done, the dentist doesn't work there anymore.

They think like you. You have money and you only let the prosthodontist to work on you.

 

[Cold Front]

Affluent people are not going to put up with the long wait time, rude assistants, and clueless receptionists at the call centers. They are not going to see a dentist at corp who recommends 10 cavity fillings. And when then they come back to get those fillings done, the dentist doesn't work there anymore.

They think like you. You have money and you only let the prosthodontist to work on you.

Affluent people are small in numbers. Not really a growth driven market. Corporations (just like us) also understand - the more affluent the patient is, the more picky/demanding and critical that patient can be to the dentist and the office. Some don’t really care and still see any dentist, they are just too busy with life like other patients.


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[2TH MVR]

Affluent people are not going to put up with the long wait time, rude assistants, and clueless receptionists at the call centers. They are not going to see a dentist at corp who recommends 10 cavity fillings. And when then they come back to get those fillings done, the dentist doesn't work there anymore.

They think like you. You have money and you only let the prosthodontist to work on you.

I totally agree. But like I said .... they are popping up in my area. Just a couple. These are not the big box Dental Corps I'm talking about. These are the smaller Corp practices (Pac Dental, Heartland Dental practices). You know .... the Corp practices that look like private practices.

 

[ToothJockey]

Because of the uncertainty of the future of dentistry, people shouldn't be going to dental school if it costs them more than 200k NET (meaning you shouldn't owe more than 200k at the end of your education). After graduating, get into ownership fast, HUSTLE, invest heavily. The main priority is keeping yourself and your family SAFE.....meaning roof to live under, food on the table, no more slavery to debt.

Financial independence = Freedom

 

[knewstance]

Because of the uncertainty of the future of dentistry, people shouldn't be going to dental school if it costs them more than 200k NET (meaning you shouldn't owe more than 200k at the end of your education). After graduating, get into ownership fast, HUSTLE, invest heavily. The main priority is keeping yourself and your family SAFE.....meaning roof to live under, food on the table, no more slavery to debt.

Financial independence = Freedom

I mean that's a really nice idea and I agree with you, but it's unrealistic in our current education climate for the majority of students/potential students.

I don't think that we can decrease the costs of dental school unless enrollment starts to heavily drop. The other option that I see is learning to make more money (like you are suggesting), this is something that dentists are working with/against on a daily basis vs insurance companies and competing for patients vs corps.

 

[ToothJockey]

I mean that's a really nice idea and I agree with you, but it's unrealistic in our current education climate for the majority of students/potential students.

I don't think that we can decrease the costs of dental school unless enrollment starts to heavily drop. The other option that I see is learning to make more money (like you are suggesting), this is something that dentists are working with/against on a daily basis vs insurance companies and competing for patients vs corps.

Too much truth here man. These school costs are a huge reason many future dentists won't be able to achieve financial independence. It's very hard to keep school costs at 200k or below if you don't have parental help/HPSP/Scholarships. But with the future of dentistry as it is, I truly think those who will graduate owing 600k+ will be in for a life of debt slavery. It's all a domino effect. High debt, tough to buy a practice, forced to work as an associate for years meaning most of your money goes towards loans (student loans, mortgage, auto etc.), no money to invest.

That's why I encourage pre-dents to only attend dental school if they can come out owing ~200k or less. Some will make it work even with 400k+ in loans, but majority won't. Once enrollment drops as you said, schools will close down, tuition prices will drop, grads won't be forced to work for corporate anymore, less saturation...dentistry can be great again!

 

[knewstance]

That's why I encourage pre-dents to only attend dental school if they can come out owing ~200k or less.

Without some kind of outside help (parents, HPSP, scholarships ect.), this is not possible. SIU is the least expensive dental school and COA assuming you are an IL resident is $206k after interest accrued during school.

I think most recent grads from most state schools can make it work even if they aren't real go-getters or business savvy. With an average starting income at about $130k and loan payments around $2500/mo for 20 years (assuming ~$350K debt) you can still live an acceptable life. It's not what most pre-dents dream of and they could be better off by pursuing a different career, but it's still very doable. As your income increases, you can pay off loans more quickly, move into ownership, invest, ect ect.

 

[ToothJockey]

Without some kind of outside help (parents, HPSP, scholarships ect.), this is not possible. SIU is the least expensive dental school and COA assuming you are an IL resident is $206k after interest accrued during school.

I think most recent grads from most state schools can make it work even if they aren't real go-getters or business savvy. With an average starting income at about $130k and loan payments around $2500/mo for 20 years (assuming ~$350K debt) you can still live an acceptable life. It's not what most pre-dents dream of and they could be better off by pursuing a different career, but it's still very doable. As your income increases, you can pay off loans more quickly, move into ownership, invest, ect ect.

Yup many grads from state schools will still live a comfortable life as a dentist, and who knows if they go into ownership and succeed they might even live a great life!

I guess my 200k limit was mostly for my plan to reach financial independence as soon as possible for a dentist. The only reason for this is the financial uncertainty in the future of dentistry. What will reimbursements look like? What will the dental economy look like? etc. etc.

I'm mostly concerned because Cold Front himself has pretty doom and gloom predictions for dentistry. And looking back to some of his posts back in the early 2010s, this man is spot on with predictions for dentistry/the dental economy. I'm not gonna bet against Cold Front LMAO

 

[charlestweed]

I totally agree. But like I said .... they are popping up in my area. Just a couple. These are not the big box Dental Corps I'm talking about. These are the smaller Corp practices (Pac Dental, Heartland Dental practices). You know .... the Corp practices that look like private practices.

They are smaller but they are still corp offices. And like big corp offices, they hire a bunch of staff and dentists, who don’t care about the office the same way the private practice owners care about theirs. The employee turnover rate is high. The patient-doctor relationship is almost nonexistent. When patients have money and good PPO insurances, they want the see a dentist whom they can trust. If a private practice dentist loses his patients to these corp offices, then there must be something wrong with this dentist’s clinical and communication skills.

 

[charlestweed]

Affluent people are small in numbers. Not really a growth driven market. Corporations (just like us) also understand - the more affluent the patient is, the more picky/demanding and critical that patient can be to the dentist and the office.

You are right. There are not enough rich people out there to keep your practice successful. The bottom 80% income earners are more abundant in number. That’s why I don’t setup my offices in affluent areas like many of my colleagues. There are already too many existing dental/ortho offices that try to target the affluent patients in these areas. Big corps did their research when they set up their offices. And I just set mine up right next to these corp offices to compete against them.

Some don’t really care and still see any dentist, they are just too busy with life like other patients.

And once they see the chaos, the rude staff and the lack of doctor-patient relationship, they will switch to a different dentist, who accepts their insurance plans. Word of mouth is the key to grow your business. With such poor service, corp offices don't get a lot of word of mouth referrals....they get patients because they accept insurance plans that private practices don't accept.