EFTA00601113.pdf

PPR-30-2009 10.1E3A FAttl:DR *CMS MOWN' 2123979308 10:16467067223 P.1. 1 Thomas J. Magnani D.D.S. G-R.ILA Telephone: (212) 688-1090 (71 , 17\ Alvin Grayson D.D.S. 7 West 51st Street IS piratical& wine re WORE yours pre btu rattan stn. arc fair Mew 7th Floor Aran New York NY 10019 1f . et4 Toacterel to Cr IP Dot° suture yon Jeff Epstein Date Account Ilibe 413012009 9118 St Thomas Virgin Islands 00802 Remittance OrPORTANT. PLEASE MICH UPPER MEW NC Paula vaTNYOUR REPARTANCE TORSUTtE CREW TO PROPER ACCO IRA Date Patient Description Charges Credits Balance Previous Balance 0.00 4/21/2009 Andrea Comprehensive Oral eval 50.00 50.00 4/21/2009 Andrea FMS with Bite wings 175.00 225.00 4/21/2009 Andrea Bite Wings 4 Films 65.00 290.O0 4/2112009 Andrea Adult Scale 8 Prophy 160.00 450.00 4/2112009 Andrea Fluorid 12.00 462.00 4/22/2009 Andrea AMERICAN EXPRESS 462.00 0.00 4/29/2009 Andrea 1 Periaplcal X Ray 25.00 25.00 4/29/2009 Andrea Amalgam 4+ Surface Perm. 425.00 450.00 4/29/2009 Andrea Amalgam 4+ Surface Perm. 425.00 875.00 Account Total 876.00 Wo accept credit cards. You may complete and return the top part of this statement, or call the office at 212-888.1090. Current 30 Dayc 60 Dayc 00 Dayc 120+ Days 875.00 0.00 0.00 0.00 0.00 hOrn.vs J. tagnanl D D.S. Alvin Grayson D.D.S. 7 Vint Slit Street 7111 ROW New York NY 10019 EFTA00601113