Provider Demographics
NPI:1962478305
Name:PERNOUD, MICHAEL JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:PERNOUD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 WASHINGTON SQ
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:636-239-7586
Practice Address - Street 1:1015 WASHINGTON SQ
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:636-239-7586
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T71007Medicare UPIN