MEDICARE: DENTAL WELLNESS CENTER EB5 INVESTMENT VI LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1639717010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL WELLNESS CENTER EB5 INVESTMENT VI LLC

Provider Business Mailing Address
First Line	:	749 STOCKBRIDGE DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-7200
Country	:	US
Telephone Number	:	803-335-5585
Fax Number	:

Provider Business Practice Location Address
First Line	:	749 STOCKBRIDGE DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-7200
Country	:	US
Telephone Number	:	803-335-5585
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	SHARI MATTHEWS
Credential	:
Telephone Number	:	843-599-9590

Provider Enumeration Date	:	12/16/2019
Last Update Date	:	01/12/2020

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