EFTA00289179.pdf
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Extracted Text (OCR)
Dental Statement of Services
Account # :
New York, NY 10065
DOB:
SSN :
Rel. to Prim. Sub :
Remarks for Unusual Service
Statement Date: Wednesday, January 17, 2018
Provider
Michelle Katz
474 6th Ave
New York, NY 10011
TaxID e:
NPI # :
License #:
Phone # :
No Primary Insurance
No Secondary Insurance
Date
Code
Th
Surf
Description
Charges
Credits
1/17/2018 ZCLEA
THE CLEAN
PMT PAT-American Express
89.00
-89.00
Total as of 1/17/2018 :
89.00
-89.00
Signed (Treating Provider) :
Date :
Page 1
EFTA00289179
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This document was extracted from a PDF. No image preview is available. The OCR text is shown on the left.
Extracted Information
Document Details
| Filename | EFTA00289179.pdf |
| File Size | 26.6 KB |
| OCR Confidence | 85.0% |
| Has Readable Text | Yes |
| Text Length | 537 characters |
| Indexed | 2026-02-11T13:23:00.412950 |
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