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1

Responsible Party

2

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Responsible Party Information

Please enter the name, mobile and address for the responsible party that will be billed for this account.

First name

Middle initial optional

Last name

Account holder’s email address

Mobile Phone

Address

Suite/apt no

Address 2

City

State

ZIP code

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After creating your account, you'll receive an email to set your password.

Bliss Modern Dentistry

Location

8525 Boat Club Rd

Fort Worth, TX 76179

Phone

817-500-5288

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