=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578149001
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARTER TIMOTHY BRUETT DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2021
-----------------------------------------------------
Last Update Date | 03/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 S WAKARA WAY
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84108-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-631-5779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 530 S WAKARA WAY
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84108-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-215-9617
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12317468-9923
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0106X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
-----------------------------------------------------
License Number | 12317468-9923
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------