Healthcare Provider Details

I. General information

NPI: 1467449751
Provider Name (Legal Business Name): EDWARD H SEGAL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SHERMER RD SUITE 340W
NORTHBROOK IL
60062-5340
US

IV. Provider business mailing address

1500 SHERMER RD SUITE 340W
NORTHBROOK IL
60062-5340
US

V. Phone/Fax

Practice location:
  • Phone: 847-498-5630
  • Fax: 847-498-8801
Mailing address:
  • Phone: 847-498-5630
  • Fax: 847-498-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: