Most orthodontists who add a second location regret it inside 18 months.
Not because the second location was a bad idea. Because the operating system that ran the first location wasn’t ready to run two. The owner becomes the bottleneck, costs explode, the original location’s culture starts to drift, and what looked like growth on paper becomes pain across the board.
Multi-location growth done right is one of the most powerful business decisions an orthodontist can make. Done wrong, it’s the most common reason successful single-location practices stall or sell.
I’m Luke Infinger. The most powerful proof point in the work I’ve done is Dr. Ben Fishbein, who scaled from a $2.4 million single-location practice to over $26 million across eight offices over seven years. The lessons from that journey, and from the dozens of multi-location practices we’ve worked with since, are the foundation of how I think about expansion.
When You’re Ready to Add a Location
Most owners add their second location too early. The signal isn’t “my schedule is full.” It’s “my schedule is full, my systems are documented, my leadership team can run this office without me, and I have the cash to fund 12 to 18 months of operating losses at the new site without straining the parent practice.”
If three of those four are true, you’re close. If only one is true, expansion will hurt you.
The Four Pre-Expansion Tests
- Operational maturity. Documented SOPs for new patient flow, consult flow, financial presentation, scheduling, and team management. If any of these live only in the owner’s head, expansion will expose that.
- Leadership depth. A second-in-command who actually runs the practice when you’re not there. Not just a senior team member. A real operational leader.
- Financial cushion. Twelve to 18 months of operating cash for the new site, on top of what the parent location needs.
- A clear hiring pipeline. You should know how you’ll staff the new location before you sign the lease. The labor market is the single most common cause of new-location underperformance.
What Makes Multi-Location Growth Work
1. Systems Replication
The fastest way to break a multi-location practice is to let each location develop its own way of doing things. The fastest way to scale one is to define exactly how new patients flow, how consults run, how financials are presented, and how the schedule is built, then replicate that system at every location.
This is the work most owners skip. It’s also the work that determines whether the second location reaches profitability in 12 months or 36.
2. Leadership Delegation
Every multi-location practice that scales successfully has a real operational leader running operations across sites. Sometimes that’s a COO. Sometimes that’s a clinical director. Sometimes it’s a regional office manager. The title doesn’t matter. What matters is that the owner is no longer the answer to every operational question.
Owners who refuse to make this hire are choosing to cap their growth. There is no third location for the owner who’s still personally approving every expense at the second one.
3. Location-Level KPI Tracking
You cannot manage two locations on the back of one combined dashboard. Every location needs its own weekly KPI view: leads, exam show rate, case acceptance, same-day starts, production per provider hour, overhead percentage. Compare the locations. Find the variance. Fix the location that’s underperforming.
This is also how you spot the early warning signs of cultural drift. Numbers tell you when one location is starting to operate differently from the others, usually months before the patient experience tells you.
4. Hiring for Multiple Sites
The hiring rhythm at a multi-location practice is different. You are constantly recruiting, even when you don’t have an open position. You should always be talking to potential TCs, OMs, and providers. The cost of an unfilled key role at a second location is much higher than the cost of carrying a strong candidate’s resume in a folder for six months.
The Fishbein Story in Numbers
When I met Dr. Ben Fishbein, his practice was producing about $2.4 million from one location. Today he runs eight offices and over $26 million in annual revenue. Marketing budget tripled. Online conversion rate up 500 percent. Total revenue up more than 10x in seven years.
Underneath those numbers is a multi-location playbook that we built and refined together, location by location. Documented systems. A real leadership team. Location-level KPIs reviewed weekly. A hiring pipeline that never went cold. Each new office opened faster and reached profitability faster than the one before it because the operating system kept getting sharper.
Ben’s story is dramatic, but the principles are not unique to him. They are the same principles that work for a $5 million two-location practice deciding whether to add a third site, or a $15 million four-location group thinking about regional expansion.
When Multi-Location Doesn’t Make Sense
Not every practice should add locations. Some practices are better off staying single-location and pushing toward $5 million, $7 million, or $10 million from one site with a strong associate model. The economics of a great single location often beat the economics of three mediocre ones.
Multi-location is right for owners who want to build a regional brand, who have a clear succession plan or sale path that benefits from scale, and who genuinely enjoy the leadership work that running multiple offices requires. It is not right for owners who simply want to grow revenue and don’t care which path gets there.
What I Help With
Inside the Breakthrough program, multi-location work covers:
- Pre-expansion readiness audit
- SOP documentation and replication strategy
- Leadership structure design and key-hire coaching
- Location-level KPI dashboard build
- New-location pro forma and financial planning
- Brand and marketing strategy across locations
- Hiring pipeline development
- Founder transition planning if you’re moving from operator to overseer
Frequently Asked Questions
How long until a new location is profitable?
Twelve to 24 months is typical. Faster if your systems are mature and your hiring pipeline is strong. Longer if either is weak.
Should each location have its own brand?
Almost always no. A single brand across multiple locations builds equity faster, supports referrals across sites, and is much easier to manage marketing-wise.
How big should my leadership team be?
It depends on scale. A two-location practice can run with one strong operations leader. By four or five locations you usually need a regional leadership layer plus location-level office managers.
Is it harder to sell a multi-location practice?
Harder to sell to a single individual orthodontist. Easier and more lucrative to sell to a DSO or PE buyer. The right exit path depends on the structure of the group.