MEDICARE: MARISSA LYNN GENTLE 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	1223P0700X	Prosthodontics	11146	SC
2	390200000X	Student in an Organized Health Care Education/Training Program		NC
3	122300000X	Dentist	11146	SC

General Provider Information

NPI Number	:	1063143519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA LYNN GENTLE DMD

Provider Business Mailing Address
First Line	:	300 E MCBEE AVE STE 300
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-2899
Country	:	US
Telephone Number	:	864-522-8611
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 RICHLAND MEDICAL PARK DR STE A
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6892
Country	:	US
Telephone Number	:	803-434-6567
Fax Number	:	803-434-6299

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

Provider Enumeration Date	:	06/23/2022
Last Update Date	:	02/16/2026

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