2123979008 TO:16467067223 r• 1 1 P "ent MAR-22-2002 09:58 FROM:DR.MAGNANI Thomas J. Magnani D.D. Alvin Grayson D.D.S. 7 West 51St Street 7th Floor New York NY 10018 Mr. Jeff Epstein 301 East 66th Street Apt 1OF New York NY 10066 Date 1/4/2013 1/4/2013 1/4/2013 1/9/2013 1/29/2013 1/30/2013 Current Description Recall ral Exam Adult Sale & Prophy Add Per apical X Rays Amalgti 2 Surface Perm. Porcel4 1 W. Gold Crown Case t mplete HISTORICAL STATEMENT 1/1/2013 to 3/21/2013 Charges Dole Telephone: Account 9648 3/21/2013 40.00 180.00 10.00 375.00 900.00 0.00 Credits Balance 40.00 220.00 230.00 605.00 1,505.00 1,505.00 Account Total 1,505.00 Patient Charges 1,505.00 Patient Payments 0.00 Patient Credits 0.00 Patient Debits 0.00 60 Days ¢ 90 Days Thomas J. Megnani D.D.S Ahrin Grayikst D.D.S. 7 West Stet Str New York NY 10019 120+ Days EFTA00705196