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Plan Requir ements & Limita tions EAST HAMPTON DENTAL GROUP PREFERRED PROVIDER PLAN The Preferred Provider Plan is available to all families and individuals who pay the annual subscriber fee. The annual plan fee must be paid in full when submitting the application. Enrollment Family & Individual Plans Available is open to all. Your plan year will be determined by the date when you submit your payment and will be for a 12 month period. This is an independent dental plan, offered by a private practice and we are not associated with any other office. We reserve the right to cancel or make changes to the plan at any time. Only dental services provided at East Hampton Dental Group are covered by this plan. Care Credit can not be used as form of pay- East Hampton Dental Group 56 The Circle East Hampton , NY 11937 ment. After 45 days, cost of plan is not refundable, but can be used as credit for services. Jan. 2015 Phone: 631-324-6800 Fax: 631-324-7744 East Hampton Dental Group 631-324-6800 www.ehdental.com Plan Pricing Services Provided We utilize state-of-the-art techniques, materials and advanced technology to attend to all your comprehensive dental needs. Our team of dentists and dental specialists provide: General Dentistry Advanced Restorative Dentistry Cosmetic Dentistry Oral and Maxillofacial Surgery Dental Implants Invisalign Orthodontics I.V. Sedation (sleep dentistry) Periodontics (gum treatment) Endodontics (root canal treatment) Pediatric Dentistry Digital radiographs Oral Cancer Screening Teeth Whitening In-Office ICAT radiograph Saturday hours 24 hour emergency answering service Individual Plan—1 Adult Per 12 month period Two dental cleanings with examinations, 1 full-set of radiographs or 4 check-up X-rays + panoramic x-ray, oral hygiene instruction, oral cancer screening, nutritional counseling, one emergency exam with x-ray. $425 Teen Plan—13 to 19 years Per 12 month period Two dental cleanings with examinations, 1 full-set of radiographs or 4 check-up x-rays + panoramic x-ray, oral cancer screening, oral hygiene instruction, nutritional counseling, one emergency exam with x-ray, screening for braces. $375 Child Plan—up to 12 years Per 12 month period Two dental cleanings with examinations and fluoride treatment, 1 full-set of check-up x-rays, oral hygiene instruction, oral cancer screening, nutritional counseling, one emergency exam with x-ray, screening for braces. $340 Family Plan—4 people Per 12 month period Dentists and Dental Specialists David A. Mambrino, D.D.S. Advanced Restorative & Cosmetic Dentistry Ven Sampathkumar, D.D.S. Advanced Restorative & Cosmetic Dentistry Navid Rahmani, D.D.S. practice limited to Periodontics and Dental Implants Jack A. Nelson, D.D.S. practice limited to Oral Surgery, Dental Implants and Dental Anesthesiology Dental Hygienists Tara Turner R.D.H. Nicole Kalafut, R.D.H. A private preferred provider plan offered by East Hampton Dental Group Two dental cleanings with examinations, 1 full-set of radiographs or 4 check-up x-rays + panoramic x-ray, fluoride treatment, oral hygiene instruction, oral cancer screening, nutritional counseling, screening for braces and one emergency exam with x-ray. $1475 East Hampton Dental Group All plans include a 15% discount on restorative and endodontic treatment and a 10% discount on oral and periodontal surgery and orthodontic treatment. Phone: 631-324-6800 Fax: 631-324-7744 E-mail: [email protected] 56 The Circle East Hampton, NY 11937 www.ehdental.com