Healthcare Provider Details

I. General information

NPI: 1376388835
Provider Name (Legal Business Name): MARISSA GARDNER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PARK AVE
SAINT LOUIS MO
63104-3024
US

IV. Provider business mailing address

1221 11TH AVE S
ESCANABA MI
49829-3005
US

V. Phone/Fax

Practice location:
  • Phone: 314-252-8196
  • Fax:
Mailing address:
  • Phone: 906-241-7830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901602898
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: