Healthcare Provider Details

I. General information

NPI: 1679241467
Provider Name (Legal Business Name): IAN BRODERICK SEGALL DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2021
Last Update Date: 07/28/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7242 TYLERS CORNER DR
WEST CHESTER OH
45069-6335
US

IV. Provider business mailing address

423 HOGE ST APT 310
CINCINNATI OH
45226-1348
US

V. Phone/Fax

Practice location:
  • Phone: 513-777-7060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30.027438
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: