Provider Demographics
NPI:1639217698
Name:RAE, IAN MELVILLE (DMD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:MELVILLE
Last Name:RAE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2281 COBBLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5747
Mailing Address - Country:US
Mailing Address - Phone:937-847-9359
Mailing Address - Fax:
Practice Address - Street 1:5538 PHILADELPHIA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3062
Practice Address - Country:US
Practice Address - Phone:937-278-0703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0221351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice