📄 Extracted Text (150 words)
STATEMENT OF ACCOUNT
CHART NO. I PAGE NO. 1
7W51 DENTAL GROUP
7 W 51st Street
BILLING DATE
Floor 7
New York, NY 10019 D2/7 (222' 1
GUARANTOR NAME AND MAILING ADDRESS
Ms
1D02" AMOUNT ENCLOSED I
THE STATEMENT WITH YOUR PAYMENT
TO ENSURE PROPER CREDIT. PLEASE DETACH AND RETURN THIS PORTION OF
raw TlirSPORTIONOg
W . PATIENTS NAME CHARGES CREDITS
DATE DESCRIPTION
220.00
01/01/2017 Balance Forward
-223 00
01/12/2017 Pre-Conversion Person Payment
Drugs/medicaments for home use 24.00
01/19/2017
OVER 30 DAYS OVER 60 DAYS OVER 90 DAYS TOTAL BALANCE
CURRENT BALANCE
0.00 0 00 C 00 24.00
24.00
credit card please fill out the credit card information in
For your convenience. we offer the option of payment by Visa and Maste'Card Wnen paying by
the remittance portion above
(.5.: 1987-2012 Henry Schein. Inc. 7W51 DENTAL GROUP - 7 W 51st Street Floor 7 New York. NY 10019 (212)688-1090
EFTA00313687
ℹ️ Document Details
SHA-256
cea914b8331ee2ba35fb94f0cdf7706c5efb15c418186f275c1014fa0bc52a71
Bates Number
EFTA00313687
Dataset
DataSet-9
Document Type
document
Pages
1
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