Dental Statement of Services Statement Date: Wednesday, January 17, 2018 Account # , Provider Michelle Katz New York, NY 10065 474 6th Ave co: New York, NY 10011 SSN: TaxID # : 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 : Page 1 EFTA00289179