# REGGIE H. BROOM, D.M.D., P.A.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215280672
- **Authorized official:** DR. REGGIE HARRIS BROOM D.M.D. (PEDIATRIC DENTIST/OWNER)
- **Authorized official phone:** (228) 896-5197

## Contact information

- **Practice address:** 1635 E PASS RD, GULFPORT, MS 39507-3527
- **Practice address phone:** (228) 896-5197
- **Practice address fax:** (228) 896-5192
- **Mailing address:** 1635 E PASS RD, GULFPORT, MS 39507-3527
- **Mailing address phone:** (228) 896-5197
- **Mailing address fax:** (228) 896-5192

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | 2005-83 | MS | Yes |

## Other

- **Enumeration date:** 10/23/2012
- **Last updated:** 10/23/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 07734393 | — | MS |
| 05 | — | 09015230 | — | MS |
| 01 | — | 466176 | UNITED CONCORDIA | MS |