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CHART NO. PAGE NO.
Thomas J. MagnanL D.D.S.
7W51 DENTAL GROUP 1
7 W 51st Street. Floor 7 614/111ONTDI! :; DUE DATE
Nsia11.19 (16/14/2017 07/14/2017
CREDIT CARD a EXP
NAME
GUARANTOR NAMEAND MAILING ADDRESS As i emeareenconli
Mr Jeff Epstein
9 East 71st Street SIGNATURE
New York, NY 10021 TYPE OF CARD
laP tatifftac LCISED
SECURITY CODE
TO:ENSURE PROPER CREDIT,:
iimatvo.ftwootioriiiib6404.10034si
PLEASE RETAIN SKS PORTION OF DIE STATEMENT FOR YOUR RECORDS
//ga r
WPOW CREDITS
-117, 0
1'
05/01/2017 Balance Fonvard 0.00
05/18/2017 Prophylaxis-adult Jeff 180.00
05/18/2017 Periork oral evaluation Jeff 40 00
F-..a/RIENT,BA10400. ::::?,:WERi.(SAYD -li GO &ORS : :.'0W 14
-11420/01. ,; ' 'it iikitige l i CE
220.00 0.00 0.00 0.00 220.00
Make charts payable to: Thomas J. Magnin. DDS. To pay by Credit Card, please cal our
office at
PLEASE PAY ina,
220.00
THIS AMOUNT nr
01987-2012 Henry Schein, Inc. Thomaill'Unrani. D D S - 7W51 DENTAL GROUP 7 W Slst Street, Floor 7 New York. NY 10019
EFTA00316345
ℹ️ Document Details
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Bates Number
EFTA00316345
Dataset
DataSet-9
Document Type
document
Pages
1
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