NEW IMAGE DENTISTRY INC.

Contacts

Phone	+1 321-434-4444

Authorized person

Name	MOHAMMED M AHMED
Role	ASSOCIATE DENTIST
Phone	3214344444

Taxonomy

Taxonomy Code	122300000X - Dentist
License Number	DN21406
State	FL
Is Primary	Yes

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

Signature of

Role	Plan administrator
Date	2013-10-15
Name of individual signing	TATIANA POMBO
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2013-10-15
Name of individual signing	TATIANA POMBO
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1997-01-01
Business code	621210
Sponsor’s telephone number	3212544334
Plan sponsor’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940

Plan administrator’s name and address

Administrator’s EIN	593583903
Plan administrator’s name	NEW IMAGE DENTISTRY
Plan administrator’s address	7827 N. WICKHAM ROAD, SUITE C, MELBOURNE, FL, 32940
Administrator’s telephone number	3212544334

Signature of

Role	Plan administrator
Date	2012-08-22
Name of individual signing	TATIANA POMBO
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2012-08-22
Name of individual signing	TATIANA POMBO
Valid signature	Filed with authorized/valid electronic signature