By Arun Ramakumar, Founder & CEO, Integrated Dental Partners | San Francisco Bay Area
Most dentists over 50 see two conventional exit routes: sell to a national DSO or sell to a local dentist. There is a third option: partner with a regional DSO
Most dentists over 50 think they have two options when it’s time to step back. They have three and most never hear about the third until it’s too late to use it.
It usually goes something like this: “I have built something real here. I know I will not run it forever. Do I sell to a national DSO? Do I find a local dentist to take it over? Or is there a way to step back from the business burden without giving up everything I built?”
That is a more accurate version of the succession question facing many practice owners over 50. The decision is not simply whether to sell. It is what kind of transition fits the owner’s goals, the team, the patients, and the next five or ten years of the dentist’s life.
I previously wrote about why I chose to build a regional DSO instead of a national one. This article examines that decision from the other side of the table, through the eyes of a dentist considering what comes next.
Traditionally, the two sale paths are clear: sell to a national DSO or sell to another local dentist. Both can be good outcomes. But both begin with the assumption that the answer is a sale. That may be the first mistake. Succession is not a single decision called “sell.” The first question should be: what do you want your role, your practice, and your financial relationship to the practice to look like after the transition?
The Time to Plan for Succession Is Now
Practice ownership is heavily concentrated among mid and late career dentists. That makes succession planning a present tense issue for the profession, not a distant one.
Experienced dentists who have spent decades building patient relationships, clinical reputations, and community trust are reaching the point where the question of what comes next is no longer abstract.
Path one: sell to a national DSO
The national DSO route solves real problems. It can provide substantial liquidity, a defined transaction process, and the ability to transfer a large portion of the administrative burden to an organization with scale. For a dentist who wants a relatively clear path toward a full exit, that can be attractive.
The tradeoff is control. Once the practice is sold, decisions about staffing, systems, scheduling, procurement, branding, and future strategy may increasingly be made at a level above the individual office. Some national groups preserve local culture well; others standardize aggressively. The point is not that the model is inherently good or bad. It is that the seller needs to understand what will actually remain under local control after closing.
This is also the moment worth understanding what’s happening industry-wide with national DSO economics – the pressure many of these groups are under right now is starting to change the terms sellers can expect.
If your priority is maximum liquidity and a defined exit, a national DSO may be the right buyer. If your priority is preserving the exact identity and operating style of the practice, you need to examine the post-sale reality just as carefully as the purchase price.
Path two: sell to a local dentist
The traditional alternative is to sell the practice to another dentist, often someone local who wants to become an owner. This can feel more personal. The buyer may know the community, may want to preserve the practice name and team, and may be personally invested in maintaining the patient relationships that made the practice successful.
But this path has its own constraints. The transaction depends heavily on one buyer’s financing, management ability, clinical fit, and willingness to take on the full responsibilities of ownership. A good clinician is not automatically a good operator. A buyer may also have a very different vision for staffing, technology, hours, specialty mix, or growth once the handoff is complete.
Selling to a local dentist can be an excellent succession plan when the right successor exists. But it is still a sale. At some point, the seller gives up control, the buyer takes over, and the future value of the practice belongs primarily to the new owner.
The third path: partner with a regional DSO
The third path is different because the starting point is not, ‘Who should buy my practice?’ It is, ‘What if I do not need to sell the whole thing in order to solve the problems that are wearing me down?’
A regional DSO partnership can be structured around economic alignment, operational support, and a more gradual transition, while preserving the clinical ownership and control required under applicable state law. The dentist can continue practicing and remain meaningfully connected to the practice, while the regional partner takes on agreed parts of the business infrastructure that are consuming time and energy.
At Integrated Dental Partners, the model is built around operating partnership rather than absorption. This is the same idea I described as regional stewardship the neighborhood practice isn’t a problem to be solved; it’s an asset to be protected. HR, compliance, procurement, technology infrastructure, recruiting, and other back-office functions can be supported centrally. The goal is not to erase the local practice. It is to make the practice easier to own and easier to operate while protecting the clinical culture, patient relationships, and community identity that already work.
The timing matters. Waiting until burnout, an unexpected health issue, or an urgent retirement deadline forces the decision can narrow the owner’s options and negotiating leverage. A regional partnership allows the dentist to make the transition earlier: continue practicing clinically, transfer agreed non-clinical responsibilities, create some liquidity, and retain an economic interest in what happens next. For a dentist who still enjoys patient care but no longer wants to carry the full operational burden, that can be a very different proposition from selling the entire business.
For the right dentist, that creates a different equation: some liquidity and support today, continued clinical involvement if desired, and participation in future upside rather than a one-time handoff. It can also create a more deliberate succession runway instead of forcing the owner to move from full responsibility to full exit in one transaction.
This is not automatically the best path. If you want to retire immediately, maximize cash at closing, and never think about the practice again, a partnership may be the wrong structure. But if you still enjoy dentistry and are mainly tired of running the business around it, a full sale may be solving a problem you don’t actually have.
The real decision is not national versus local
That is the central point. A dentist over 50 should not begin with the question, ‘Should I sell to a national DSO or a local dentist?’ The better question is, ‘Do I want a complete sale at all?’
If the answer is yes, then compare the national and local buyer paths on economics, certainty, cultural fit, transition expectations, and what happens to the team. If the answer is no, or not yet, then a regional partnership belongs in the conversation.
Tax structure can matter, too
Taxes should not determine which succession path a dentist chooses, but they can materially affect how a transaction is structured. If a transaction is structured so that the dentist monetizes part of the economic value today while retaining or rolling over an interest that is sold in a later tax year, qualifying taxable gain may be recognized across multiple years rather than concentrated in one year. Because federal long-term capital-gains rates are progressive, that timing can matter. A large one-year gain can push a greater portion of the sale into the highest long-term capital-gains bracket, while a staged transaction may allow the seller to use lower capital-gains brackets again in a later year. For California dentists, timing can matter at the state level as well because California taxes capital gains as ordinary income and imposes an additional 1% tax on taxable income above $1 million.
That does not mean a partnership automatically produces a lower tax bill. A dental-practice transaction is not one uniform capital gain. Goodwill, equipment, receivables, and other assets can receive different tax treatment, and depreciation recapture may be taxed as ordinary income. The legal structure of the transaction also matters, and a full sale can sometimes be structured as an installment sale. Future tax rates and the value of any retained interest may also change, so the ultimate tax outcome cannot be known at the time of the first transaction. But for an owner who wants to remain economically invested, monetizing part of the value now and the remainder later can create a legitimate tax-planning opportunity in addition to providing liquidity today and preserving participation in future upside. The structure should be modeled with the seller’s CPA and tax attorney before any transaction is signed.
This article is for general informational purposes only and is not tax, legal, or financial advice. Every seller’s situation is different, and tax outcomes depend on individual facts and circumstances. Sellers should consult their own CPA or tax advisor before making any decisions related to a sale or partnership transaction.
The questions worth asking before any decision
If you are a dentist over 50 and beginning to think about succession, these are the questions I would get clear on before talking seriously with any buyer or partner, including us.
What do you want your own role to look like in five years? Do you want to be fully retired, practicing two days a week, or still clinically active without carrying the operational burden? Your answer immediately narrows the right structure.
How important is liquidity today? A full sale to a national DSO or local dentist may produce more immediate liquidity. A partnership may preserve more ongoing economic participation. Neither is universally better; they serve different goals.
What do you want the practice to look like in five years? If the name, team, patient experience, and community presence matter deeply to you, make those issues explicit before price dominates the conversation.
What does your team need? The clinical assistant who has been with you for twelve years and the front desk coordinator your patients ask for by name are part of the value of the practice. Ask what happens to them under each path.
What are you actually tired of? Many owners are not tired of dentistry. They are tired of HR issues, compliance, recruiting, vendor negotiations, technology decisions, payroll, and the constant responsibility of being the only person ultimately accountable. If that is the real problem, a complete sale is not the only solution.
How much control are you truly willing to give up? Every succession structure changes control. The important thing is to understand where decisions will sit after the transaction or partnership, not just during the transition period.
What happens if you need to step back suddenly? A good succession structure should work even if illness, family needs, or simple burnout changes your timeline. That question is easier to answer before there is urgency.
The conversation most dentists wish they had earlier
One thing I hear consistently from dentists who begin exploring these options is that they wish they had started the conversation earlier.
Waiting until burnout is severe or retirement feels urgent reduces your options. A national DSO, a local dentist, and a regional DSO partnership should be compared while you still have the time and leverage to choose among them thoughtfully.
If you are over 50 and running a dental practice, and the question of what comes next is somewhere in the back of your mind, that is the right time to understand the three paths. Not to sign anything. Not to commit to a direction. Just to understand what you would be giving up, what you would be keeping, and what each structure is actually designed to accomplish.
Are You a Bay Area Dentist Thinking About What Comes Next?
Whether you’re five years from succession or simply feeling the weight of running a solo operation, the conversation I’m always happy to have is this: What does your practice mean to you, and what do you want its next chapter to look like?
No pitch. No pressure. No term sheet on the first call.
→ Connect with Arun Ramakumar on LinkedIn or visit integrateddentalpartners.com to start that conversation. This conversation matters whether you’re the dentist, the practice manager, or the advisor sitting across the table.
About the Author
Arun Ramakumar is the Founder and CEO of Integrated Dental Partners, a regional dental service organization based in the San Francisco Bay Area. Before founding IDP, he spent eighteen years as CEO of Accu Dental & Orthodontics, growing it from a single practice into a multi-location Bay Area group. That experience, including watching a national DSO acquisition process up close, is what shaped his conviction that the regional stewardship model is the right path for independent Bay Area dentists. He writes on DSO consolidation, dental practice succession, and what community-based dental care actually looks like in practice.
