Provider Demographics
NPI:1629055322
Name:BROMAN, JERRY PAUL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:PAUL
Last Name:BROMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DENTAC HQS
Mailing Address - Street 2:4441 SERVICE DRIVE
Mailing Address - City:FT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5054
Mailing Address - Country:US
Mailing Address - Phone:254-287-2705
Mailing Address - Fax:254-287-1786
Practice Address - Street 1:DENTAC HQS
Practice Address - Street 2:4441 SERVICE DRIVE
Practice Address - City:FT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5054
Practice Address - Country:US
Practice Address - Phone:254-287-2705
Practice Address - Fax:254-287-1786
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME164561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice