Healthcare Provider Details

I. General information

NPI: 1427210780
Provider Name (Legal Business Name): JARED RALPH COLLETT DMD, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 110, 1 JUFFAIR AVENUE NAVAL SUPPORT ACTIVITY BAHRAIN
FPO AE
09834
BH

IV. Provider business mailing address

PSC 851 BOX 340
FPO AE
09834-0004
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 318-439-4211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD011535
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60034324
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: