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CLARK L. JENNINGS, MD, INC. 1414 N. NEVADA AVE CSC 80907 Name: First: Middle Initial: Last: Address: City: State: Zip: Social Security #: Birthdate: / / Sex: Home Phone: () Work: () Cell: () Other:

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Roy Rosenthal MD 1414 is a form used for reporting certain financial transactions to the Internal Revenue Service (IRS).

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