Provider Demographics
NPI:1215280672
Name:REGGIE H. BROOM, D.M.D., P.A.
Entity type:Organization
Organization Name:REGGIE H. BROOM, D.M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGGIE
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:BROOM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-896-5197
Mailing Address - Street 1:1635 E PASS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3527
Mailing Address - Country:US
Mailing Address - Phone:228-896-5197
Mailing Address - Fax:228-896-5192
Practice Address - Street 1:1635 E PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3527
Practice Address - Country:US
Practice Address - Phone:228-896-5197
Practice Address - Fax:228-896-5192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2005-831223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015230Medicaid
MS466176OtherUNITED CONCORDIA
MS07734393Medicaid