MEDICARE: TD EAST BURNSIDE GPS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1922953298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TD EAST BURNSIDE GPS LLC

Provider Business Mailing Address
First Line	:	1200 SE SANDY BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-1347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 SE SANDY BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-1347
Country	:	US
Telephone Number	:	503-419-6499
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	WILLIAM LITTLE
Credential	:	DDS
Telephone Number	:	503-419-6499

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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