Provider Demographics
NPI:1013190875
Name:MICHAEL AND ANGELA PERNOUD, DDS, PC
Entity Type:Organization
Organization Name:MICHAEL AND ANGELA PERNOUD, DDS, PC
Other - Org Name:HAWK RIDGE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:K
Authorized Official - Last Name:PERNOUD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:636-561-4540
Mailing Address - Street 1:8631 HIGHWAY N
Mailing Address - Street 2:
Mailing Address - City:LAKE ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367
Mailing Address - Country:US
Mailing Address - Phone:636-561-4540
Mailing Address - Fax:636-561-4601
Practice Address - Street 1:8631 HIGHWAY N
Practice Address - Street 2:
Practice Address - City:LAKE ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367
Practice Address - Country:US
Practice Address - Phone:636-561-4540
Practice Address - Fax:636-561-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006021264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty