Event :: The World of Oral Medicine October 17 2015 :: Confirmation Page 11/10/15 13:17

Thank you! Your registration is complete. A summary appears below.

Purchases

REGISTRATION RATES

Type Cost

Other health care professionals $200.00

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Registration Details

First Name
Marcel

Last Name
Balthazar

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Event :: The World of Oral Medicine October 17 2015 :: Confirmation Page 11/10/15 13:17

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Orthodonist

Email
marcelbalthazar@gmail.com

Street Address 1
Rua Lemos Cunha, 315 ato 1401

Street Address 2

City
Niteri

State
Rio de Janeiro - Brazil

Zip Code
24210-330

Telephone
5521988941972

Fax number

Total
Total Amount: $200.00

Payment Details

Address
Rua Lemos Cunha 315 apto 1401 - Acarai

City
Niteri

State
Other

Zip
24230-131

Country
BRAZIL

Phone
5521988941972

Name as It Appears on Card

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Credit Card Type

**********

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Event :: The World of Oral Medicine October 17 2015 :: Confirmation Page 11/10/15 13:17

Card Number
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Card Identification Number

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Expiration Date
****/****

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