Provider Demographics
NPI:1659538973
Name:MICHAEL J PERNOUD DDS PC
Entity Type:Organization
Organization Name:MICHAEL J PERNOUD DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/SEC
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PERNOUD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:1636-239-5959
Mailing Address - Street 1:1015 WASHINGTON SQ STE F
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-5307
Mailing Address - Country:US
Mailing Address - Phone:636-239-5959
Mailing Address - Fax:
Practice Address - Street 1:1015 WASHINGTON SQ STE F
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-5307
Practice Address - Country:US
Practice Address - Phone:636-239-5959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty