DSO Spotlight
After several years focused on strengthening its existing operations, 42 North Dental is returning to the acquisition market with renewed capital, a refined partnership model and a greater emphasis on doctor recruitment, mentorship and succession planning.
42 North Dental is preparing for its next phase of expansion, but the New England-based dental support organization is not simply returning to the acquisition strategy it used several years ago.
The organization, which supports more than 100 practices across nine states, spent much of the past several years strengthening its existing operations, improving practice-level support and addressing the pressures that affected the broader dental industry following the pandemic.
Now, with a refinanced balance sheet and additional capital available for growth, 42 North Dental is once again actively pursuing affiliations. This time, however, the organization is placing even greater importance on discipline, cultural alignment and long-term partnership.
Group Dentistry Now spoke with Priyanki Amroliwala, senior manager of talent acquisition, and Greg Wappett, chief development officer, about the organization’s renewed growth strategy, the changing doctor recruitment market and what practice owners should consider before affiliating with a DSO.
A Return to the Acquisition Market
Wappett recently returned to 42 North Dental after previously leading its corporate development initiatives from 2016 through 2021.
During his first tenure, the organization grew from approximately 30 locations to nearly 100 practices. Before 2014, the company, formerly known as Gentle Dental and General Dental Partners, had grown almost entirely through de novo development.
After adding private equity capital, 42 North began incorporating acquisitions into its growth strategy. From approximately 2016 through 2022, the organization added close to 50 practices.
That pace eventually slowed as the operating environment became more difficult.
Many of the acquired practices included some form of succession planning for their selling doctors. The pandemic accelerated retirement and reduced-work schedules for some clinicians who had originally expected to remain with their practices for several more years.
At the same time, labor expenses increased, staffing became more difficult and inflation raised the cost of operating dental practices. Rising interest rates also increased the cost of acquisition financing and servicing existing debt.
Rather than continue acquiring practices simply to maintain a growth target, 42 North paused.
The organization redirected its attention toward improving the practices already within its network, strengthening internal systems and finding better ways to grow within its existing locations.
“We realized that this was the right time to focus our initiatives and our thoughts internally,” Wappett said. “How can we grow within the four walls of our practices as opposed to just going out and trying to find ways to finance more acquisitions?”
The slower acquisition period gave operational teams time to absorb the organization’s earlier growth and evaluate where systems, integration processes and practice support could be improved.
Following a recent refinancing, 42 North now has additional capital available for growth and a balance sheet structured for the current economic environment.
Greg Wappett
“We’re growing organically, we’re ready to grow inorganically and now we’ve got the balance sheet that’s appropriately structured for today’s environment,” Wappett said.
The organization is not interested in buying practices merely to increase its location count.
“We need to do it in a disciplined fashion,” he added. “We’re not just buying for the sake of buying.”
What 42 North Looks for in an Affiliation
Although financial performance remains important, Wappett said the most successful affiliations depend heavily on whether the practice owner’s goals and expectations align with those of the DSO.
42 North is primarily a general dentistry organization. More than 95% of its practices are rooted in general dentistry, with only a small number of specialty-focused locations.
The organization generally looks for practices with at least six operatories, or the ability to expand to six or more. Approximately $1.5 million in annual revenue and $300,000 to $350,000 in adjusted EBITDA represent the lower end of its typical acquisition profile.
However, the practice must also have meaningful opportunities for growth.
That could include adding another general dentist, expanding hygiene services, introducing in-house specialty care or extending office hours. The practice owner must also be willing to support that growth.
The organization’s model is built around larger, collaborative practices with multiple providers. A dentist who wants to remain the sole clinical decision-maker without adding associates or specialists may not be the right fit.
“We always have at least two GPs in the practice,” Wappett said. “Our model is much more collaborative, with multiple providers, larger practices and busier practices.”
When evaluating an opportunity, one of the first questions Wappett asks is why the dentist wants to sell.
Some owners are seeking an immediate retirement. Others want to reduce their administrative responsibilities while continuing to practice for another decade or more. Some are primarily focused on monetizing the business they have built.
Each motivation requires a different affiliation structure and transition plan.
Wappett encourages sellers to be realistic about how long they want to remain with the practice. A stated five-year commitment may not mean the same thing to both parties if the dentist expects to gradually reduce from five clinical days per week to one.
“Going into partnerships under false pretenses is the wrong way to think about this,” he said.
Practice owners must also recognize that selling changes their role. They may retain significant clinical influence, but they are no longer the sole business owner making every operational decision independently.
That adjustment can be difficult for dentists who have led their practices for decades.
“Decisions need to be made collaboratively,” Wappett said. “We look for people who are open-minded about the idea of partnership.”
Preserving the Practice While Adding Support
One common concern among sellers is that a DSO will immediately change the identity, payer mix or staffing model of the practice.
Wappett said 42 North does centralize functions that can be efficiently managed through a support organization, including accounting, human resources, benefits, insurance negotiations and purchasing.
However, the company does not apply a single operating model to every practice.
For example, it supports several fee-for-service practices and does not automatically require them to begin accepting additional insurance plans. It also does not reduce employee compensation simply because another practice within the network operates with a different cost structure.
“Every practice is different,” Wappett said. “It’s not a cookie-cutter approach.”
One significant operational change is the conversion to the organization’s practice management system. A common system allows 42 North to gather consistent business information and provide useful analytics to practice leaders.
The data is intended to help practices identify opportunities, compare performance and learn from similar offices within the network.
The organization does not expect every location to operate identically. Instead, its scale provides more than 100 reference points for understanding how different practices manage scheduling, hygiene, patient flow, treatment acceptance and other areas.
“You don’t just join a DSO like 42 North simply for a financial transaction,” Wappett said. “You’ve got 100-plus offices with multiple providers across each one of them that you can leverage for best practices.”
Recruitment and Succession Must Work Together
Acquisitions cannot succeed without an effective doctor recruitment strategy, particularly when an affiliation includes a retiring or slowing-down owner.
Amroliwala has been with 42 North Dental for nearly 11 years and leads its doctor recruitment efforts. She said the recruiting environment has become progressively more challenging.
Dentists, specialists, hygienists and dental assistants remain in limited supply, while the cost of dental education is influencing career and employment decisions. Many new dentists enter the workforce with $300,000 to $400,000 in educational debt.
At the same time, dental schools are facing their own staffing and patient-access challenges. Some graduates are entering practice with less clinical experience and a greater need for structured support.
42 North has responded by expanding its recruiting team, strengthening its relationships with dental schools and building a more formal clinical mentorship structure.
The organization is located near Boston University, Harvard University and Tufts University, allowing its recruitment team to maintain a consistent presence within several dental school communities.
Priyanki Amroliwala
Amroliwala acknowledged that dental school relationships may not produce immediate hires. However, she believes organizations that consistently support students and become part of the dental school community will build stronger recruiting pipelines over time.
“The more that you build a robust program within these dental schools, the bigger your talent pool is going to be,” she said.
Building a More Structured Mentorship Model
All 42 North practices have multiple doctors, allowing newer associates to work alongside an experienced lead dentist, known internally as the director of the practice.
New doctors may also have opportunities to work with and shadow in-house specialists.
The organization has added regional clinical directors who participate in the interview process and remain involved after the doctor is hired. New associates receive structured 30-, 60- and 90-day check-ins to assess their progress and determine whether additional clinical or operational support is needed.
The goal is to avoid placing a new graduate in a practice without adequate guidance.
“It’s not just throwing someone into the fire,” Amroliwala said.
Mentorship has become an increasingly important recruitment tool as younger dentists evaluate employment opportunities. Many new graduates are looking for clinical guidance, predictable compensation and an environment where they can build confidence.
Amroliwala has also seen more experienced dentists seek part-time positions before making a full commitment. They may initially work one or two days per week while remaining at another practice.
She described the approach as a “try before you buy” model. If the doctor connects with the team, sees sufficient patient demand and finds the practice culture appealing, the arrangement may eventually become full-time.
Hiring for Growth Mindset and Soft Skills
Clinical ability is only one component of a successful hire.
When recruiting a director of the practice, 42 North generally looks for a dentist with at least three years of experience in a fee-for-service or PPO environment.
The individual must also be able to lead a team, build relationships with patients and work effectively with hygienists, assistants, front office employees and the practice manager.
Most importantly, the organization looks for a growth mindset.
A director must be comfortable bringing additional associates and specialists into the practice rather than attempting to remain the only provider.
“When someone says, ‘I want to be the only doctor in the practice,’ that is already a red flag for us,” Amroliwala said.
The same collaborative mindset is important when recruiting associates. Clinical skills can continue to develop through experience and mentorship, but interpersonal skills and attitude are more difficult to change.
“We trust that the dentistry is good and the dentistry will get there,” Amroliwala said. “Your clinical ability and skill will improve over time. The biggest thing is the soft skills.”
Challenging Common DSO Misconceptions
Both Amroliwala and Wappett continue to hear concerns that DSOs impose unrealistic production expectations, prioritize financial performance over patient care or remove clinical autonomy.
Amroliwala said some dental students are still advised to avoid DSOs or to use them only as temporary training grounds before moving into private practice.
However, she has also seen students become more open to group practice opportunities, particularly as DSOs continue to hire and invest in structured mentorship.
Wappett noted that performance expectations are not unique to DSOs. Private practice owners also monitor production, collections and profitability, particularly when employing associate dentists.
The difference is that larger organizations can provide more data and comparative information.
At 42 North, those analytics are used to help clinical and practice leaders understand what is occurring within their offices and identify potential opportunities. The organization does not attempt to dictate individual treatment plans or force every office to operate in the same way.
Providing transparency around those expectations is important for both employment candidates and prospective affiliation partners.
Not every dentist will be a fit for 42 North, and 42 North will not be the right organization for every practice.
For Wappett, the best partnerships often begin long before a transaction. Some dentists currently speaking with him first explored an affiliation five or even 10 years ago.
Their circumstances, priorities or retirement timelines have since changed, but the existing relationship allows the conversation to resume from a position of familiarity and trust.
“A lot of these come from years’ worth of conversations and building that relationship, trust and knowledge exchange,” Wappett said.
As 42 North begins its next period of growth, that relationship-driven approach will remain central to its strategy.
The organization has the capital to pursue acquisitions again. Its larger challenge will be finding practice owners, associates and clinical leaders who share its vision for collaboration, mentorship and sustainable growth.
For 42 North, the next stage is not simply about adding more practices.
It is about finding the right people to grow them.
Watch Priyanki and Greg on the Group Dentistry Now podcast:
