=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124664743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R MATHIS 002 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2019
-----------------------------------------------------
Last Update Date | 11/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2830 REIDVILLE RD
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29301-5640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-574-0762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 230 N GROVE MEDICAL PARK DR
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29303-4222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-310-6888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DALLAS BURNETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-415-0931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------