MEDICARE: DR. MICHAEL JAMES PERNOUD D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	12314	MO

General Provider Information

NPI Number	:	1962478305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL JAMES PERNOUD D.D.S.

Provider Business Mailing Address
First Line	:	1015 WASHINGTON SQ
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-5307
Country	:	US
Telephone Number	:	636-239-5959
Fax Number	:	636-239-7586

Provider Business Practice Location Address
First Line	:	1015 WASHINGTON SQ
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-5307
Country	:	US
Telephone Number	:	636-239-5959
Fax Number	:	636-239-7586

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. MICHAEL JAMES PERNOUD D.D.S.” Practice Location

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