Provider Demographics
NPI:1427210780
Name:COLLETT, JARED RALPH (DMD, PA-C)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:RALPH
Last Name:COLLETT
Suffix:
Gender:M
Credentials:DMD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16433 KEATS TER
Mailing Address - Street 2:
Mailing Address - City:DERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20855-1920
Mailing Address - Country:US
Mailing Address - Phone:509-438-4786
Mailing Address - Fax:
Practice Address - Street 1:8960 BROWN DRIVE
Practice Address - Street 2:BLDG 9, FLOOR 2
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-5629
Practice Address - Country:US
Practice Address - Phone:301-400-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60034324363AS0400X
AZD011535122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1427210780Medicaid
WA0251709OtherLABOR & INDUSTRIES
WA0251709OtherLABOR & INDUSTRIES