Doctor Name: | REGGIE HARRIS BROOM |
NPI Number: | 1063588788 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | DMD |
License Number: | 11986 |
Business Practice Address: | 1635 E Pass Road Gulfport, MS - 39507 |
Business Phone Number: | 2288965197 |
Business Fax Number: | 2288965192 |
Mailing Address: | 1635 E Pass Road, GULFPORT |
State: | MS |
Postal Code: | 39507 |
Phone Number: | 2288965197 |
Fax Number: | 2288965192 |
NPI Enumeration Date: | 11/27/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 1223P0221X |
License Number: | 11986 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | MS |
Taxonomy Type: | Dental Providers |
Taxonomy Classification: | Dentist |
Taxonomy Specialization: | Pediatric Dentistry |
Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |