EFTA01196766.pdf

HISTORICAL STATEMENT 12/1/2014 to 3/3/2015 Thomas J. Magnanl D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr. Jeff Epstein Date Account 9 East 71st Street 3/2/2016 9648 New York NY 10021 serntnence NEPOOTANT PLEASE OETACII UPPER PORTION NC RETURN WITH YOUR M IIITYNCE TO INSURE MOO TO PROPER ACCOutir Date I Patient Description Charges Credits Balance 8/20/2014 Previous Balance 0.00 12/17/2014 Amalgam 2 Surface Perm. 350.00 350.00 12/17/2014 Recall Oral Exam 40.00 390.00 12/17/2014 Adult Scale & Prophy 180.00 570.00 12./17/2014 Bite wings 4 Films 65.00 635.00 1/8/2015 Panoramic Film 0,00 635.00 1/8/2015 Ortho treatment adult 7,500.00 8,135.00 1/30/2015 AMERICAN EXPRESS 635.00 7,500.00 2/9/2015 1 Periapical X Ray 25.00 7,525.00 Account Total 7,626.00 Patient Charges 8,160.00 Patient Payments 636.00- Patient Credits 0.00 Patient Debits 0.00 We accept credit cards You may comply top part of this statement, or call the office sail. Current 30 Days 60 Days 90 Days 120* Days 26.00 7,600.00 0.00 0.00 0.00 moon J. JAsonsnl 0 D.S. AMA Orsylon D.D.S. 7 Weal 51st Stress 7th Floor New York NY 10019 EFTA01196766