Provider Demographics
NPI:1578149001
Name:BRUETT, CARTER TIMOTHY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARTER
Middle Name:TIMOTHY
Last Name:BRUETT
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 1:2244 JACKSON AVE APT 2209
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-9439
Mailing Address - Country:US
Mailing Address - Phone:801-215-9617
Mailing Address - Fax:
Practice Address - Street 1:56-45 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-670-1507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT12317468-9923122300000X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist