Dental Statement of Services Account # : New York, NY 10065 DOB: SSN : Rel. to Prim. Sub : Remarks for Unusual Service Statement Date: Wednesday, January 17, 2018 Provider Michelle Katz 474 6th Ave New York, NY 10011 TaxID e: NPI # : License #: Phone # : No Primary Insurance No Secondary Insurance Date Code Th Surf Description Charges Credits 1/17/2018 ZCLEA THE CLEAN PMT PAT-American Express 89.00 -89.00 Total as of 1/17/2018 : 89.00 -89.00 Signed (Treating Provider) : Date : Page 1 EFTA00289179