Healthcare Provider Details

I. General information

NPI: 1083119770
Provider Name (Legal Business Name): TRENT MICHAEL COLLETT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 PIEDMONT RD NE STE 113
ATLANTA GA
30305-1506
US

IV. Provider business mailing address

1129 KIRK PL
AUGUSTA GA
30909-3478
US

V. Phone/Fax

Practice location:
  • Phone: 404-647-4120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN015665
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDN015665
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: