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General NPI Number Information
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NPI Number | 1215280672
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Entity Type | Organization
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Legal Business Name | REGGIE H. BROOM, D.M.D., P.A.
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Dates
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Enumeration Date | 10/23/2012
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Last Update Date | 10/23/2012
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Provider Practice Location Address
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Address Line | 1635 E PASS RD
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City | GULFPORT
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State | MS
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Zip | 39507-3527
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Country | US
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Telephone | 228-896-5197
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Fax | 228-896-5192
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Provider Business Mailing Address
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Address Line | 1635 E PASS RD
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City | GULFPORT
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State | MS
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Zip | 39507-3527
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Country | US
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Telephone | 228-896-5197
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Fax | 228-896-5192
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Authorized Official
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Title or Position | PEDIATRIC DENTIST/OWNER
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Name | DR. REGGIE HARRIS BROOM
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Credential | D.M.D.
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Telephone | 228-896-5197
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2005-83
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License Number State | MS
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