MEDICARE: DR. VELVET ENJOLI MARTIN DMD

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	11440	NC

General Provider Information

NPI Number	:	1871152041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VELVET ENJOLI MARTIN DMD

Provider Business Mailing Address
First Line	:	111 GARWIN DR W APT 2B
Second Line	:
City	:	WILSON
State	:	NC
Zip	:	27893-2769
Country	:	US
Telephone Number	:	252-443-7764
Fax Number	:

Provider Business Practice Location Address
First Line	:	8282 NC 58 S
Second Line	:
City	:	ELM CITY
State	:	NC
Zip	:	27822-8079
Country	:	US
Telephone Number	:	252-443-7764
Fax Number	:	252-443-7611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	04/16/2020

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