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General NPI Number Information
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NPI Number | 1063143519
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Entity Type | Individual
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Provider Name | MARISSA LYNN GENTLE DMD
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Gender | Female
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Dates
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Enumeration Date | 06/23/2022
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Last Update Date | 08/22/2025
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Provider Practice Location Address
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Address Line | 10 RICHLAND MEDICAL PARK DR STE A
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City | COLUMBIA
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State | SC
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Zip | 29203-6892
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Country | US
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Telephone | 803-434-6567
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Fax | 803-434-6299
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Provider Business Mailing Address
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Address Line | 300 E MCBEE AVE STE 300
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City | GREENVILLE
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State | SC
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Zip | 29601-2899
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Country | US
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Telephone | 864-522-8611
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 11146
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | NC
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