Provider Demographics
NPI:1215917687
Name:RISSER, MARJORIE J (DMD)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:J
Last Name:RISSER
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 1:372 S HERLONG AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1160
Mailing Address - Country:US
Mailing Address - Phone:803-324-1160
Mailing Address - Fax:803-324-2456
Practice Address - Street 1:372 S HERLONG AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1160
Practice Address - Country:US
Practice Address - Phone:803-324-1160
Practice Address - Fax:803-324-2456
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC33711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ33713Medicaid
SCZ33713Medicaid
SC2015Medicare PIN