EFTA00638123.pdf

STATEMENT Thomas J. Magnani D.D.S. Telephone: Alvin Grayson D.D.S. 7 West 61st Street ■ pare by cret54 cud. *Mr the amount you re wow mar molten WON N oul below 7th Floor Mastecan1 Mese AMOY New York NY 10019 Cardo bp Dais SONS, SO Code Mr. Jeff Epstein Dab Account 9 East 71st Street 1/7/2015 10055 New York NY 10021 Remittance IMPORTANT PEASE DETACH UPPER PORTION ANO RETURN NTH YOUR RESETTNCE TO INSURE CREW TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 11/26/2014 Previous Balance 0.00 12/15/2014 Sue Recall Oral Exam 40.00 40.00 12/15/2014 Sue Adult Scale & Prophy 180.00 220.00 12/18/2014 Sue Amalgam 2 Surface Perm. 425.00 645.00 Account Total 645.00 If payment has been sent, please disregard this statement - Thank You. We accept credit cards! You may complete atop part of this statement, or call the office at Current 645.00 30 Days 0.00 4 60 Days 0.00 90 Days 0.00 1 120+ Days 0.00 Thomas J. Magnin' D.D.S. Alv:n Grayson D.D.S. 7 West 51st Street 7th Floor New Yolk NY 10019 EFTA00638123