Provider Demographics
NPI:1558508689
Name:BREUER, JOHN T (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:BREUER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1245
Mailing Address - Country:US
Mailing Address - Phone:631-553-5267
Mailing Address - Fax:
Practice Address - Street 1:100 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2004
Practice Address - Country:US
Practice Address - Phone:631-289-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041529122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist