Provider Demographics
NPI:1447885173
Name:BROOM, DIANE ZYBKO (DMD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ZYBKO
Last Name:BROOM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:CAROLYN
Other - Last Name:ZYBKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:323 KOON TRESTLE RD
Mailing Address - Street 2:
Mailing Address - City:POMARIA
Mailing Address - State:SC
Mailing Address - Zip Code:29126-8979
Mailing Address - Country:US
Mailing Address - Phone:843-687-5902
Mailing Address - Fax:
Practice Address - Street 1:2039 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2249
Practice Address - Country:US
Practice Address - Phone:803-276-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC95691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice