1922366228 NPI number — DR. ROBERT KEITH BROOME JR. DDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922366228 NPI number — DR. ROBERT KEITH BROOME JR. DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOME
Provider First Name:
ROBERT
Provider Middle Name:
KEITH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922366228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10700 MEDLOCK BRIDGE ROAD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
JOHNS CREEK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-813-0079
Provider Business Mailing Address Fax Number:
770-814-7407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3875 HOLCOMB BRIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
NORCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30092-5287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-447-9808
Provider Business Practice Location Address Fax Number:
770-447-6002
Provider Enumeration Date:
04/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  9711 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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