EFTA01154410.pdf

NPR-30-2009 10.18:1 FRI:thDR 'MOWS rYiGTYifJ1 2123sr9uoti 10:16467067223 P.1, 1 Air IL-R.11A Thomas J. Magnani D.D.S. rejThnn Telophono: Alvin Grayson D.D.S. 7 West 51st Street roirg was& cantors& re swanrosy proctors nommoi S.ro fair bob.. 7th Floor Mosiontrel Ms New York NY 10019 Can a Do Dee spa.. *gems Jeff Epstein Date Account 4130/2009 9118 St Thomas Virgin Islands 00802 Remittance 0ZPORTNIT•PWASC MUCH UPPER Maw:* mePima MN YOUR ODER/NM TONSURE CREW TO PROPER ACCC tAT Date Patient Description Charges Credits Balance Previous Balance 0.00 4/21/2009 Comprehensive Oral eval 50.00 50.00 4/21/2009 FMS with Bite wings 175.00 225.00 4/21/2009 Bite Wings 4 Films 65.00 290.O0 4/2112009 Adult Scale 8 Prophy 160.00 450.00 4/21/2009 Fluorid 12.00 462.00 4/22/2009 AMERICAN EXPRESS 462.00 0.00 4/29/2009 1 Periaplcal X Ray 25.00 25.00 4129/2009 Amalgam 4+ Surface Perm. 425.00 450.00 4/29/2009 Amalgam 4+ Surface Perm. 425.00 875.00 Account Total 876.00 Wo accept credit cards. You may complete and return the top part of this statement, or call the office at 212-888.1090. Current 30 Dayc 60 Dayc 00 Dayc I 120+ Days 875.00 0.00 0.00 0.00 I 0.00 Thomas J. Magnint D D.S. Mtn Grtyson D.D.S. 7 Mot Sin SUM 718 Floor New York NY 10019 EFTA01154410