Case File
efta-efta00313687DOJ Data Set 9OtherSTATEMENT OF ACCOUNT
Date
Unknown
Source
DOJ Data Set 9
Reference
efta-efta00313687
Pages
1
Persons
0
Integrity
Extracted Text (OCR)
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STATEMENT OF ACCOUNT
7W51 DENTAL GROUP
7 W 51st Street
Floor 7
New York, NY 10019
GUARANTOR NAME AND MAILING ADDRESS
Ms
1D02"
CHART NO.
I
PAGE NO.
1
BILLING DATE
D2/7(222'1
AMOUNT ENCLOSED I
TO ENSURE PROPER CREDIT. PLEASE DETACH AND RETURN THIS PORTION OF THE STATEMENT WITH YOUR PAYMENT
DATE
raw TlirSPORTIONOg
DESCRIPTION
W
.
PATIENTS NAME
CHARGES
CREDITS
01/01/2017
Balance Forward
220.00
01/12/2017
Pre-Conversion Person Payment
-223 00
01/19/2017
Drugs/medicaments for home use
24.00
CURRENT BALANCE
OVER 30 DAYS
OVER 60 DAYS
OVER 90 DAYS
TOTAL BALANCE
24.00
0.00
0 00
C 00
24.00
For your convenience. we offer the option of payment by Visa and Maste'Card Wnen paying by credit card please fill out the credit card information in
the remittance portion above
(.5.: 1987-2012 Henry Schein. Inc.
7W51 DENTAL GROUP - 7 W 51st Street Floor 7 New York. NY 10019 (212)688-1090
EFTA00313687
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Phone
(212)688-1090Forum Discussions
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