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Complete the next parts to complete the document:
You should submit the Tooth System, MISSING TEETH INFORMATION, Permanent, Primary, d o f, A B C D E, F G H I, T S R Q P, O N M L K, f o d, AUTHORIZATIONS, ANCILLARY CLAIM/ TREATMENT, Radiograph(s) Oral Image(s), Model(s), and Provider’s Office field with the appropriate information.
You'll be requested to write down the data to help the platform fill in the part 52A, © 2006 American Dental Association, J400 (Same as ADA Dental Claim, To Reorder call 1-800-947-4746 or, X Signed (Treating Dentist), Date, and 56A.
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