Organization
REGGIE H. BROOM, D.M.D., P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. REGGIE HARRIS BROOM D.M.D. (PEDIATRIC DENTIST/OWNER)
(228) 896-5197
Entity
Organization
Contact information
Practice address
1635 E PASS RD, GULFPORT, MS 39507-3527
(228) 896-5197
(228) 896-5192
Mailing address
1635 E PASS RD, GULFPORT, MS 39507-3527
(228) 896-5197
(228) 896-5192
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
2005-83
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07734393
—
MS
05
—
09015230
—
MS
01
—
466176
UNITED CONCORDIA
MS
Enumeration date
10/23/2012
Last updated
10/23/2012
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