MEDICARE: TD NE PORTLAND 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	:	1659226926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TD NE PORTLAND GPS LLC

Provider Business Mailing Address
First Line	:	3500 NE MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-2093
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 NE MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-2093
Country	:	US
Telephone Number	:	503-765-7355
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MATT KATHAN
Credential	:
Telephone Number	:	503-765-7355

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	04/14/2026

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Directions to “TD NE PORTLAND GPS LLC ” Practice Location

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