Case File
efta-efta00289179DOJ Data Set 9OtherDental Statement of Services
Date
Unknown
Source
DOJ Data Set 9
Reference
efta-efta00289179
Pages
1
Persons
0
Integrity
Extracted Text (OCR)
Text extracted via OCR from the original document. May contain errors from the scanning process.
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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