Provider Demographics
NPI:1699880492
Name:PERRARD, AI M (DDS)
Entity type:Individual
Prefix:DR
First Name:AI
Middle Name:M
Last Name:PERRARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:AI
Other - Middle Name:
Other - Last Name:MITOME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:308 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-2752
Mailing Address - Country:US
Mailing Address - Phone:512-398-6122
Mailing Address - Fax:512-213-0820
Practice Address - Street 1:308 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644-2752
Practice Address - Country:US
Practice Address - Phone:512-398-6122
Practice Address - Fax:512-213-0820
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX223911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176055503Medicaid
TX176055507Medicaid
TX176055501Medicaid
TX176055502Medicaid
TX176055505Medicaid
TX176055506Medicaid