02/11/2016 13:34 2123155160 NUSIKANT DEUTSCH PC PAGE 01/02
PRACTICE LIMITED TO ENDODCVTIC3 a I 24.413.10368
FAX Q12-316-6160
STEVEN D KAPLAN, D.M.D.
ALEN JiAK0B, D.M.D.
PRACTICE LimIrmo To ENOODONTICS
119W8ST57STREET
P. 212 - 245-1066 SUITE 700
C. 917 - 576-2698 NEW YORK. N.Y. 10019
FAX CO ER LETTER
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Number Of Pages Including This Cover Sheet
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EFTA01185864
02/11/2016 13:34 2123155160 MUSIKANT DEUTSCH PC PACE 02/02
PATIENT Strkatti wsteast
DATE ACCOUNT NO.
Steven D Kaplan, DMD
119 West 57th Street 02/11/2016 9617-0
Suite 700
New York
(212) 245-1066
NY 10019
MC
PATIENT DESCRIPTION CHARGE CREDIT EXPECTED INS PATIENT CHARGE
Ret reatatent -molar 25C.0.3C .00 2500.00
C2/11/2016 ADA: D3348 Tooth: 19
Steven D. Kaplan Tax ID. 133161736
LIC. 034161
SUIVAIARY INSURANCE PATIENT ADDITIONAL INFORmATIONAPPOINTNENT SCHEDULING
PREVIOUS ACCOUNT BALANCE .00 .00
CHARGES FOR TODAY'S VISIT .00 + 2500.00
PAYMENT .00
CURRENTACCOUNT BALANCE .00 2500.00
TOTAL OBLIGATION 2 500.00
PLEASE PAY THIS AMOUNT --> 2500.00
If your insurance company pays more than expected, you win be credied the difference. II your insurance company pays less than eVected,
you will be charged the difference. Friel nasponsibdity for payment rests with the person to whom this receipt is addressed.
EFTA01185865