Provider Demographics
NPI:1700457942
Name:MARTIN, NICHOLE LILLIAM (DMD)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LILLIAM
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 EDDINGS DR APT 103
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-1195
Mailing Address - Country:US
Mailing Address - Phone:305-335-1277
Mailing Address - Fax:
Practice Address - Street 1:8020 NORTHLAKE CREEK DR STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-4487
Practice Address - Country:US
Practice Address - Phone:305-335-1277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26190122300000X
NC13607122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist