Provider Demographics
NPI:1679241467
Name:SEGALL, IAN BRODERICK (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:BRODERICK
Last Name:SEGALL
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 HOGE ST APT 310
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45226-1348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7242 TYLERS CORNER DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-6335
Practice Address - Country:US
Practice Address - Phone:513-777-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-06
Last Update Date:2024-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0274381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty