EFTA01185864.pdf

02/11/2016 13:34 2123155160 NUSIKANT DEUTSCH PC PAGE 01/02 PRACTICE LIMITED TO ENDODCVTIC3 a I 24.413.10368 FAX Q12-316-6160 STEVEN D KAPLAN, D.M.D. ALEN JiAK0B, D.M.D. PRACTICE LimIrmo To ENOODONTICS 119W8ST57STREET P. 212 - 245-1066 SUITE 700 C. 917 - 576-2698 NEW YORK. N.Y. 10019 FAX CO ER LETTER Date: c;- IL Lk To: 2 ( it i From: ;( k :-,(eiLJ“ ---31 ../ .i, cr:› Number Of Pages Including This Cover Sheet Comments: 1--s.\!; ._ 17- #(17--, CCOICLALVZ-51C DNS .-11C-P,r1 / 4.1-et/t. OtfrCW, .---i---- cei,.4 EFTA01185864  02/11/2016 13:34 2123155160 MUSIKANT DEUTSCH PC PACE 02/02 PATIENT Strkatti wsteast DATE ACCOUNT NO. Steven D Kaplan, DMD 119 West 57th Street 02/11/2016 9617-0 Suite 700 New York (212) 245-1066 NY 10019 MC PATIENT DESCRIPTION CHARGE CREDIT EXPECTED INS PATIENT CHARGE Ret reatatent -molar 25C.0.3C .00 2500.00 C2/11/2016 ADA: D3348 Tooth: 19 Steven D. Kaplan Tax ID. 133161736 LIC. 034161 SUIVAIARY INSURANCE PATIENT ADDITIONAL INFORmATIONAPPOINTNENT SCHEDULING PREVIOUS ACCOUNT BALANCE .00 .00 CHARGES FOR TODAY'S VISIT .00 + 2500.00 PAYMENT .00 CURRENTACCOUNT BALANCE .00 2500.00 TOTAL OBLIGATION 2 500.00 PLEASE PAY THIS AMOUNT --> 2500.00 If your insurance company pays more than expected, you win be credied the difference. II your insurance company pays less than eVected, you will be charged the difference. Friel nasponsibdity for payment rests with the person to whom this receipt is addressed. EFTA01185865