Dental Statement of Services
Statement Date: Wednesday, January 17, 2018
Account # : Provider
Michelle Katz
New York, NY 10065 474 6th Ave
DOB: New York, NY 10011
SSN : TaxID e: NPI # :
Rel. to Prim. Sub : License #:
Phone # :
Remarks for Unusual Service No Primary Insurance No Secondary Insurance
Date Code Th Surf Description Charges Credits
1/17/2018 ZCLEA THE CLEAN 89.00
PMT PAT-American Express -89.00
Total as of 1/17/2018 : 89.00 -89.00
Signed (Treating Provider) : Date :
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