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April 24, 2024

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Invoice Number:138355
Billing Period:01/01/2007 - 01/31/2007

Dental Group Number:20883-000-00000-28011
Group Name:FULLY INSURED 
Master Number:00000
Description: 
Phone Number:(999) 999-0000

FULLY INSURED
100 MAIN STREET
ANYWHERE, USA 55555-0000

STATEMENT OF ACCOUNT
Billing Period: 01/01/2007 - 01/31/2007
Due Date: 01/01/2007

Prior Due
 Prior Amount Due$2,035.92 
 Less Payment Received 2,035.92 
 Balance From Prior Billing .00 
 
Current Due
 Total Subscriber Adjustments$163.36 
 Current Billed 2,339.88 
 Balance From Current Billing 2,339.88 
 
Total Amount Due
 Total Amount Due$2,503.24 
     

Please make checks payable to: DELTA DENTAL

Payments and changes not reflected on this invoice will appear on the next invoice.

PLEASE RETURN THIS STATEMENT OF ACCOUNT PAGE WITH YOUR PAYMENT.

 
Group Name: FULLY INSURED
Dental Group Number: 20883-000-00000-28011
 
Dental Amount Due: $ 2,503.24
Dental Amount Submitted: $ ______________________________________
 
Signature:  
 

Please send all remittance to:
DELTA DENTAL
PO BOX 999
ANYWHERE USA 55555