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  • Rowena Zambrano Itemized Receipt - 2021-11-04 - 14-19-10-473520 PDF

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    Santiago Garzon
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    This dental services statement documents orthodontic treatment for Rowena Zambrano by Dr. Michael Guirguis. The treatment is comprehensive orthodontic treatment of the adult dentition over 4 months at a cost of $1,950, which was paid in full via two card payments on September 15, 2021. No balance remains on the account.

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    Rowena Zambrano Itemized Receipt_2021-11-04_14-19-10-473520.pdf

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    This dental services statement documents orthodontic treatment for Rowena Zambrano by Dr. Michael Guirguis. The treatment is comprehensive orthodontic treatment of the adult dentition over 4 months at a cost of $1,950, which was paid in full via two card payments on September 15, 2021. No balance remains on the account.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    26 views1 page

    Rowena Zambrano Itemized Receipt - 2021-11-04 - 14-19-10-473520 PDF

    Uploaded by

    Santiago Garzon
    This dental services statement documents orthodontic treatment for Rowena Zambrano by Dr. Michael Guirguis. The treatment is comprehensive orthodontic treatment of the adult dentition over 4 months at a cost of $1,950, which was paid in full via two card payments on September 15, 2021. No balance remains on the account.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    Dental Services Statement

    Patient: State Licensed Dentist:


    Rowena Zambrano Dr. Michael Guirguis
    2710 Gateway Oaks Drive Suite 150N
    Ship to: Sacramento, California 95833-3505
    Rowena Zambrano License Number: DDS61154
    3901 EAGLE ROCK BLVD UNIT 11 NPI: 1407077498
    LOS ANGELES CA 90065-3674 Taxonomy: 1223G0001X

    Bill to: Treatment Information:


    Rowena Zambrano Order Date: 9/15/2021
    3901 EAGLE ROCK BLVD UNIT 11 Duration: 04 Months
    LOS ANGELES CA 90065-3674 Case Number: C5d772ffe6633a

    Product Description CDT Code


    Comprehensive Orthodontic Treatment of the Adult Dentition D8090

    Payment Summary
    Single Pay Product Cost $1,950.00
    Discount $0.00
    Subtotal $1,950.00
    Transaction Date Payment Method Order Reference Number Transaction Amount
    9/15/2021 Card Number 5050 S2109-74eed8e69b811 Payment $700.00
    9/15/2021 Card Number 3562 S2109-74eed8e69b811 Payment $1,250.00
    Total Paid $1,950.00
    Adjustment $0.00
    Balance $0.00

    Total balance amounts may vary due to late fees and interest rates.

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