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General NPI Number Information
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NPI Number | 1265868863
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Entity Type | Individual
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Provider Name | GREGORY PERNOUD DDS
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Gender | Male
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Dates
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Enumeration Date | 09/16/2013
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Last Update Date | 09/16/2013
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Provider Practice Location Address
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Address Line | 1204 E STATE ROUTE 72
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City | ROLLA
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State | MO
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Zip | 65401-3938
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Country | US
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Telephone | 573-364-1934
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Fax | 573-364-8110
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Provider Business Mailing Address
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Address Line | 112 S 2ND ST
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City | FESTUS
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State | MO
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Zip | 63028-2201
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Country | US
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Telephone | 636-937-1515
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Fax | 636-937-0790
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 012735
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License Number State | MO
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