Individual
REGGIE HARRIS BROOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
1635 E PASS ROAD, GULFPORT, MS 39507
(228) 896-5197
(228) 896-5192
Mailing address
1635 E PASS ROAD, GULFPORT, MS 39507
(228) 896-5197
(228) 896-5192
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
11986
MS
1223P0221X
Pediatric Dentistry
Primary
200583
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
H66176
UNITED CONCORDIA
MS
Enumeration date
11/27/2006
Last updated
07/08/2007
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