NPIMap

Organization Active NPI

Reggie H. Broom, D.M.D., P.a.

  • Pediatric Dentistry
  • Gulfport, MS
National Provider Identifier
1215280672
Registry record updated Oct 23, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
2005-83 Issued in MS
Legal business name
REGGIE H. BROOM, D.M.D., P.A.
Practice address
1635 E Pass Rd
Gulfport, MS 39507-3527
Phone
(228) 896-5197
Fax
(228) 896-5192
NPI assigned
Oct 23, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 23, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Reggie Harris Broom, D.M.D.NPI 1063588788
Title
Pediatric Dentist/Owner
Phone
(228) 896-5197

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0221X 2005-83 MS Primary

Addresses

Primary practice location

1635 E Pass Rd
Gulfport, MS 39507-3527

Mailing address

1635 E Pass Rd
Gulfport, MS 39507-3527
Phone (228) 896-5197

Other identifiers 3

IdentifierTypeStateIssuer
09015230MedicaidMS
466176OtherMSUNITED CONCORDIA
07734393MedicaidMS

National Provider Directory

National Provider Directory

Locations

1635 E Pass Rd
Gulfport, MS 39507
Phone (228) 896-5197

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1350950400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350950400000",
    "number": "1215280672",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1635 E PASS RD",
            "city": "GULFPORT",
            "state": "MS",
            "postal_code": "395073527",
            "telephone_number": "228-896-5197",
            "fax_number": "228-896-5192"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1635 E PASS RD",
            "city": "GULFPORT",
            "state": "MS",
            "postal_code": "395073527",
            "telephone_number": "228-896-5197",
            "fax_number": "228-896-5192"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REGGIE H. BROOM, D.M.D., P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-23",
        "last_updated": "2012-10-23",
        "status": "A",
        "authorized_official_last_name": "BROOM",
        "authorized_official_first_name": "REGGIE",
        "authorized_official_middle_name": "HARRIS",
        "authorized_official_title_or_position": "PEDIATRIC DENTIST/OWNER",
        "authorized_official_telephone_number": "228-896-5197",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.M.D."
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "MS",
            "license": "2005-83",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09015230",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED CONCORDIA",
            "identifier": "466176",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "07734393",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Gulfport, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 23, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.