Provider Demographics
NPI:1265868863
Name:PERNOUD, GREGORY (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
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 1:112 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-2201
Mailing Address - Country:US
Mailing Address - Phone:636-937-1515
Mailing Address - Fax:636-937-0790
Practice Address - Street 1:1204 E STATE ROUTE 72
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3938
Practice Address - Country:US
Practice Address - Phone:573-364-1934
Practice Address - Fax:573-364-8110
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0127351223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery