EFTA00601113.pdf

PPR-30-2009 10.1E3A FAttl:DR *CMS MOWN' 2123979308 G-R.ILA Thomas J. Magnani D.D.S. (71 , 17\ Alvin Grayson D.D.S. 7 West 51st Street 7th Floor 1f . et4 New York NY 10019 Jeff Epstein Ilibe St Thomas Virgin Islands 00802 10:16467067223 P.1. 1 Telephone: (212) 688-1090 IS piratical& wine re WORE yours pre btu rattan stn. arc fair Mew Toacterel to Aran Cr IP Dot° suture yon Date 413012009 Account 9118 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